HMONG - RENINCous sudden nocturnal deaths in the Hmong population. Al- though these deaths also strike other ethnic groups such as the Cambodian, Filipino, Japanese, Laotian, Mien

HMONG SUDDEN UNEXPECTED NOCTURNAL

DEATH SYNDROME: A CULTURAL STUDY

by

Bruce Thowpaou Bliatout (Thojpov Npliajtub)

Sparkle Publishing Enterprises, Inc. P.O. Rox 06569

I'ortland, Oregon A7206

Copyright *:) 1982 by Hrrlce 'l'howpao~l Hliatollt

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, r t~ording or by any information storagc and rctrir:val systt:m, without permission in writing fronl the author. Inquiries should be addressed to Bruce Thowpaou Bliatont, Sparkle Publishing Enterprises, Inc., P.O. Box 06569, Portland, Ort:gon 97206.

I.ihrary of Congress Catalog Card Number: 83-72871. ISBN: 0-8323-0422-0

Printed in U.S.A.

Bruce Thowpaotr Rliatorit (Thojpov SpIiajtub) is Hrnonq. horn in 1938. and raised in Sieng Khouang. Laos. Hc n-as the son of a Farmer and has four brothers. nnc sister. four half-brothers. three half-sisters. one step-hrot her. and two step-sisters. Although Bruce's father passed away when he was about seven. he w a s fortunate to he allowed to continue his schooling bwause he helunged to one of the few Hrnonq families of that time \vho hel ie~ed in the value of education. In his late teens and durinq hi.; tv-cntim, Brucc recei~.ed a series of grants which enahled him to obtain hir higher cdt~cation in the field of Public Health In the United States.

Bruce has worked five years in the field of cro~q-cultural and social seti.ices as: 1) rldministrator and Co-Director of R.1 .C.E. (Refugees of IndocIlina Culture Edtrcation). a mental health project for refugees under the auspices of The Insti ti] te of Reha~inral Sciences. Honollllu, Han.ai i ( 197s- 113S1): 2) Promam Director of S.E.,4.R.E. [Southeast Asian Refllcee Federationl in Portland. Orecon. where h e ran a rntriti-project agency ~ e n i n c the man!, neecfs of refugees in the Portland area (mid 1SSI-mid 1982): and 3) Refrrgee Co- ordinator-Ccmmunit!. Relations for the City of Portland. Portland. Orqon. where he coordinates cross-till t u r d traininc proearns for both the refugees and cornrnlrnity a t large as \vc!l aq adds input to policy decisio~-~-making which affectr refugees (mid 19S2-present).

PREFACE

This investigation's intent was to open avenues for alternate types of research on the subject of Hmong Slldden Unexpected Noctllrnal Death Syndrome. The author hoped to promote the idea that cross-cultrlral considerations must be given when investigating a specific ethnic group.

The results of this study show that much more research is needed on the subject, and the allthor does not want to give the impression that this work has established the cause of the Hrnong Sudden Unexpected Noctr~rnal Death Syn- drome. Rather, the arithor feels he has just scratched the surface of the research needed on this subject. The author wishes to encourage other researchers and the Ilmong corn- munity to continue in their efforts to discover the mechanism of sudden nocturnal death, and how to prevent this type of death from occurring. It is the author's special hope that the Hmong youth of today will build on the present research until a solution is found. They will have the benefits of a Western education as well as knowledge of the Hxnong culture, and the commrlnity looks forward t o any future contributions from them.

ACKNOWLEDGEMENTS

I wish to acknowledge Dr. Harold A. Mooz-Kolov, Dr. Randolf Cirilo and Dr. Frederick Kingdon for their guidance and help in my doctoral studies.

I also wish to acknowledge the Columbia Hesearch Ccn- tcr o f Vancouver, Washington, particularly Bill Goldsmith and David Lansky, for the generous donation of the usage of their computer and their valuahlc advice and assistance.

I want to thank Ron Munger for sharing his research with me.

My thanks to the many Hmong commrlnity leaders throughout the country, without whose assistance this study could not have been completcd: Choua Lue Cha, Vanpheng Lee, Lytong Lysongtseng, General Vang Pao, Colonel Hang Sao, Cheu Thao, Chuc Thao, Su Thao, Colonel Tou Fu Vang, Xeuvang Vangyi, Thao Phia Xaykao, Korl Yang, Mary and Fa Yang, and Kuxeng Yongchu.

My thank also to my American parents, American grandparents and my parents-in-law: Mr. and Mrs. George Brown, Mr. and Mrs. Louis Connick, hlr. and Mrs. A. Gardener Fox, Captain and Mrs. Glenn Fulkerson, Dr. and Mrs. John Powers, and Mr. and Mrs. 1,eo Yap, for their continued support throughout my school years and during my career.

My special thanks to my cousin, Colonel Thaochay Saykao, who enabled me to be one of the few IImong of Laos to go to school those many years ago.

My acknowledgements to my youngcr set of siblings: Thowgcu Bliatout, David Thow, Nancy Saykao, Mary Saykao Yang, Thowbcc Saykao and Judy Saykao.

My most grateful thanks and acknowledgcrnents to my parents, Gaj-Lauj Bliatout Thow and Maoxay Ly Saykao; my stcp-father, Nao Vue Thao Saykao; my brothers: Pa Chay Thow, Xia Chong Thow, Wang Yang Thow, Thow- chao Bliatout, Thowthong Rliato~lt and Captain Thowsao

vii

Uliatout; and my sister Pa l'how, who all sacrificed so much in our earlier years so that I collld go to school, and for their continued lovc and support throughout my life.

My deepest appreciation to my wife, Ilollis Yap Illiatont, who has continued to support and advise me throughout this study. Without her help this investigation collld not have heen completed.

Lastly, I want to extend my gratitude to the families of the victims of Hmong Sudden Unexpected Nocturnal Death Syndrorrie who, despite their grief, were willing to donate thcir time to share information with me so that I might corrlplete this study. My deepest sy~npathy goes to all these families for thcir loss.

ABSTRACT

The IImong are an ethnic minority group found in China, Vietnam, Laos, Thailand; and since 1975, Argen- tina, Australia, Canada, France and the United States. The Hmong of I,aos were heavily involved in the cold wars of In- dochina during the 1960s and 1970s. When the Lao government changed hands in 1975, this group of people underwent diaspora.

Sincc 1973, there have been documentcd cases of mysterious sudden nocturnal deaths in the Hmong population. Al- though these deaths also strike other ethnic groups such as the Cambodian, Filipino, Japanese, Laotian, Mien and Vietnamese, by far the Hmong have experienced the highest death rates. Therefore, these deaths have become known as the Hmong Sudden Unexpected Nocturnal Death Syndrome. The deaths are associated with sleep and most victims had t~een relatively young, previously healthy men. Despite several ongoing investigations, the cause of these deaths has not yet been found.

This study was done in an attempt to discover if these sudden deaths could have some cultural origins. The Hmong concepts of health and illness are very much intertwined with their beliefs in ancestor worship. The first foclls of this study invcstigated whether beliefs in the power of spirits and other religious concepts, along with being unable to keep ~xp traditional religious practices and rituals in West- ern communities could possibly be a contributing factor to the FImong Sudden Unexpwted Nocturnal Death Syndrome. The second area of examination was to see whether the usage of traditional Hmong healing arts influenced the occurrence of these sudden deaths. Thirdly, the study considered whether membership in certain IImong snbgronps, clans or lineages was an added risk factor for sudden nocturnal death, indicating a possible genetic origin for the syndrome. Fourthly, the study questioned whether past geographic locations were common to the sudden nocturnal death victims' backgrounds. Fifth, other aspects of Hmong

culture wcrc considered for possible correlation to thcse deaths. Lastly, the study reviewed certain othcr investigators' thcorics that the sudden nocturnal deaths wcre linked to exposure to cherrlical warfare; depression causcd by the strcss of assimilating into a Western culture; terror induced t ~ y nightmares; as well as other miscellaneous theories on possible causes of these deaths.

Although no conclusive results were found, the cvidcncc suggested that the cause of sudden nocturnal dcath may he genetic in origin. Thcrc were indications that certain mem- I~ers of the IImong poprllation are predisposed to sudden dcath. However, what causes some individuals to die at ccr- tain times has not yet been determined. There was snmc evi- dcnce that the deaths were linked to the presencc of a higher level of stress. This stress was sometimes caused hy beliefs in the powers of spirits, the inability to perform traditional religiorls cerenionies and rituals in Western co~lntries, as well as a variety of othcr causes.

It also seemed possible that cxposrlre to chemical warfarc was a corrimon background for many of the s~ldden nocturnal death victims; if not exposure to an actl~al attack, then exposure to chemical residuals remaining in various areas of northern Laos. Whether this co~lld cause sudden nocturnal deaths at a later date is still under debate.

TABLE OF CONTENTS

Page . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List of Tables xiv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I, ist of Figllrcs xv

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List of Plates xv Chapter

1 . INTHODUCTION TO THE PROHI, EM OF IIMONG SUDDEN UNEXI'ECTED

. . . . . . . . . . NOCTURNAI, IIEATH SYNDROME 1 Background Informatior1 on the Hrrlong

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethnic Gmup 2 . . . . . . . . . . . . . . . . . . . . . . . . ITistory of the IImong 2

. . . . . . . . . . . . . . . . . . . . . Hmong I, ifostyle in Laos 3 . . . . . . . FImong Rcscttlemerlt in the Uriited States fi

Flmong Rcligion and its Relationship to Hmong . . . . . . . . . . . . . . . . . . . Concepts of IIcalt h and Illness 8

HrrlongI, t.gends . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 . . . . . . . . . . . . . . . . . . . . . . 'I'ypcs of Hmong Spirits 12

. . . . . . . . . . . . . . . . . . . . . . . . . . Thc Great Gods 12 .. . . . . . . . . . . . . . . . . . . . . . . . . . . 1 hc Wild Spirits 12 . . . . . . . . . . . . . . . . . . . . . . . . . Thc l'arne Spirits 14

lirnong Beliefs on CIar~ses of Illr~ess and Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ofCurcs 18

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Irlss of Soul 19 Offended or Needing Ancestor Spirit . . . . . . . . . 20

. . . . . . . . . . . . . . . . . . . . . Angered Naturc Spirit 23 . . . . . . . . . . . . . . . . . . . A Wild Evil Spirit Attack 23

. . . . . . . . . . . . . . . . A 1. oved Ono's Spirit Attack 26 Cr~rscs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

. . . . . . . . . . . . . . . . . . A Tarnc Evil Spirit Attack 28 OgreAttack . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Illness or Death by Rc:asons 0tht:r than

. . . . . . . . . . . . . . . . . . . . . . . . Spiritual CIauses 29 I'roblern of Hmong Slldden Uncxpected

. . . . . . . . . . . . . . . . . . . Nocturrlal Death Syndrome 20

. . . . . . . . . . . . . . . . . . . Descriptiorl of Syndron~e 31 Centcrs for Diseasc CIontrol's Statistics . . . . . . . . 32

. . . . . . . . . . . . . . . . . . Implications of the Deaths 33 . . . . . . . . . . . . . . . . . . . . . . . . . . . F o c ~ ~ s for Study 35

2 . HEVIEW OF PHEVIOUS AND CUHHENT HESEAHCH ON HMONG SUDDEN UNEXI'ECTED NOCTUHNAL DEA'L'H SYNDROME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 C:rrrrent Strldies on Hmong Srrddt:n Noctr~rnal

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ileaths 39 . . . . . . . . . . . . . . . . . Centers lor Disease Control 39

I'rendergast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Westerrrieyer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Mr~nger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Marshall 42 . . . . . . . . . . . . . . . . . . . . . Stanford Slccp Ccntcr 42

Rliatorit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Str~dics on Filipino Sr~ddcn Noctr~rnal Deaths . . . . 43

Marialang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Larserl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Nolasoo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

. . . . . . Investigation or1 Chemical Warfare in Laos 45 . . . . . . . . . . . . . . . . . . . . . . . . . Discr~ssion of St~rdics 48

. . . . . . . . . . . 3 . ME1'HOL)OLOC:Y AND MATEIIIAI, S 52 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IIypotheses 52

Hypothesis One-Hmong Huligiorls Reliefs . . . . 53 IIypothesis Two-Utilization of Traditional

IIcalth Practices . . . . . . . . . . . . . . . . . . . . . . . . 54 I Iypothcsis Three- . Hniong Srrt)p,rorlps,

Clans and lineages . . . . . . . . . . . . . . . . . . . . . 56 liypothcsis Four--.Past Geographic I, ocations . 57 Hypothesis Fivt:-Otlicr Aspects of

. . . . . . . . . . . . . . . . . . . . . . . . Hniong Calturc 58 . . . . . . . . . . . . . . . . . . . . Miscul1ant:oris Theories 58

. . . . . . . . . . . . . . . . . . . . . . . . . . . . I3cscarch Design 59 I'opr~lation Dc:scription . . . . . . . . . . . . . . . . . . . . 59 Description of Questionnaire . . . . . . . . . . . . . . . 60 l'rocedrire for Ckthcring Data . . . . . . . . . . . . . . fil I'roct:d~rrc for Data Analysis . . . . . . . . . . . . . . . . 62

4 . HESUL'L'S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Hypothesis 0nt:-IImong Rcligiot~s Beliefs . . . . . . 66 IIypothesis l'wo-Utilization of Traditional

. . . . . . . . . . . . . . . . . . . . . . . . . . Health I'ractices 69 Iiypothcsis Three-IIrnong Srrt)grorips,

. . . . . . . . . . . . . . . . . . . . . . . Clans and lineages 72

Hypothesis For~r- Past Ckographic Imcations . . . . 73 IIypothesis Five-Othcr Aspects of

. . . . . . . . . . . . . . . . . . . . . . . . . . Hmong Chlture 76 . . . . . . . . . . . . . . . . . . . . . . . Misccllaneorw Theories 84

. . . . . . . . . . . . Poison in a Concentration Camp 84 . . . . . . . . . . . . . . Exposr~re to Chemical Warfare 84 . . . . . . . . . . . . . . Stress of Cr~ltr~ral Assimilation 85

Hclationship to Filipino Srldclcn Noctrrrnal . . . . . . . . . . . . . . . . . . . . . . . . . . Dcath Str~dies 86

. . . . . . . . . . . . . . . . . . . . 5 . DISCUSSION OF RESUI, TS 89 . . . . . . . . . . . . . . . . . . . . . Discussion of Hypotheses 89

. . . . Iiypothesis Onc-Hmong Religious 13clicfs 89 Ilypothesis Two-Utilization of Traditional

Health Practices . . . . . . . . . . . . . . . . . . . . . . . . 93 llygothesis 'I'hrec-Hrnong Sr~hgrorlps,

. . . . . . . . . . . . . . . . . . . . . C:lans and lineages 94 IIypothesis Four-l'ast Geographic I, ocations . 96 Hypothesis Five-Other Aspects of

. . . . . . . . . . . . . . . . . . . . . . . . Hrriong CIII t ure 100 . . . . . . . . . . . . . . . . . . . . Miscellancor~s 'l'heories 102

. . . . . . . . . . Poison in a C:orlccntration Camp 102 . . . . . . . . . . . Expos~lre to Chemical Warfarc 102

. . . . . . . . . . . . Stress of C:l~ltr~ral Assimilation 104 Relationship to Filipino Sudden Nocturnal

. . . . . . . . . . . . . . . . . . . . . . . Death Str~dies 105 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclr~sions 106

. . . . . . . . . . . . . . . . . . . . . . . . . . Recorrirriendations 107 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BihliograI)hy .. 110

xiii

LIST OF TABLES

Table Page 1 . Religious Preference of the Deceased . . . . . . . . . . 67 2 . Opinion of Cause of Death . . . . . . . . . . . . . . . . . . 68

. . . . . . . . . . . . . . . . . . 3 . History of Health Problems 69 4 . Utilization of Western Medical Care . . . . . . . . . . 70 5 . Health Problems Under Western Medical Care . 71 6 . Usage of Hmong Traditional Treatments . . . . . . 71 7 . Subgroup and Clan Distribution . . . . . . . . . . . . . 72 8 . ~e la t i onsh i~ of Relative Dying Sudden Death

with Deceased . . . . . . . . . . . . . . . . . . . . . . . . . . 73 . . . . . . . . . . . . . . . . . . . . . 9 . Birthplace of Deceased 74

. . . . . . . . . . . . . . . . . . . . . . . . 10 . Thai Refugee Camp 75 11 . Place of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

. . . . . . . . . . . . . . . . . . . 12 . Income Level of Families 77 . . . . . . . . . . . . . . . . . . . . 13 . Living Space of Families 78

14 . Level of Education of Deceased . . . . . . . . . . . . . . 79 . . . . . . . . . . . . . . . . 15 . Former Employment in Laos 80 . . . . . . . . . . . . . . . . 16 . Employment in New Country 80

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17.AlcoholUsage 81 . . . . . . . . . . . . . . . . . . . . . 18 . Use of Addictive Drugs 82

. . . . . . . . . . . . . . . . . . . . . . . . . . . 19 . Use of Cigarettes 82 . . . . . . . . . . . . 20 . Use of Opium in Laos or Thailand 83

21 . Hobby of Deceased . . . . . . . . . . . . . . . . . . . . . . . . 83 . . . . . . . . . . . . . . . 22 . Exposure to Chemical Warfare 85

. . . . . . . . . . . . . . . . . . . . . . . . . . 23 . Type of Rehavior 86 24 . Resettlement Experience . . . . . . . . . . . . . . . . . . . . 8 ti 25 . Appearance of Nightmare Prior to Death . . . . . . 87 26 . Size of Last Meal . . . . . . . . . . . . . . . . . . . . . . . . . . 87

. . . . . . . . . 27 . Consumption of Fish or Fish Products 88 . . . . . . . . . . . . . . . . . . 28 . Hmong Population in Laos 97

29 . IImong Population in the United States from . . . . . . . . . . . . . . . . . . . . . . . Laotian Provinces 98

xiv

LIST OF FIGURES

Figure Page 1 Age Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 .

. . . . . . . . . . . . . . . . . . 2 . Time of Death Distribution 65 3 Number of Deaths per year . . . . . . . . . . . . . . . . . . 66 .

LIST OF PLATES

Plate Page . . . . . . . . . . . . 1 . Tools a Person with a "Neng" Uses 11

. . . . . . . . . . . . . . . . . . . . 2 . The Hmong Great Gods 13 . . . . . . . . . . . . . . . . . . . . . . . 3 . Hmong IIouse Spirits 16

. . . . . . . . . . . . . . . . . . 4 . The Hmong Diagnostician 17 . . . . . . . . . . . . . . 5 . Altar of a Person with a "Neng" 21

. . . . . . . 6 . Pcrsan with a "Neng" Entering a Trance 22 . . . . . . . . . . . . . . . . . . . . . 7 . Soul-Calling Ceremony 24

8 . Thc "Neng" Sword Used to Fight Evil Spirits . . . 25 9 . Hrnong Implement Used to ~ n t r a ~ Evil Spirits . . 27

. . . . . . . . . . . . . . 10 . Hmong Herbalist in her Garden 30

HMONG SUDDEN UNEXPECTED NOCTURNAL

DEATH SYNDROME: A CULTURAL STUDY

by Bruce Thowpaou Bliatout

(Thojpov Npliajtub)

CHAPTER 1 Introduction to the Problem of Hmong Sudden

Unexpected Nocturnal Death Syndrome

The Hmong are one of the new minority groups to arrive and settle on American soil. They are refugees from the country of Laos, but are a separate ethnic group from the lowland Laotian refugees, many of whom have also settled in the United States. The Hmong have been among us since 1975 when their homeland of Laos changed governments. The Hmong remain a close knit cultural group and have exhibited special resettlement problems.

Recently, the phenomenon of what has become known as Hmong Sudden Unexpected Nocturnal Death Syndrome has come sharply into focus as a special health problem of the Hmong. To date, there has been no conclusive evidence as to what the cause of these mysterious deaths might be. As the Hmong culture is uniquely different from even other Asian cultures, the author feels an investigation into the culture of thc Hmong could possibly give clues or indications as to reasons why sudden nocturnal dcaths are striking these people at such a high rate of occurrence.

Before beginning an investigation of possible cultural reasons for the Hmong Sudden Unexpected Nocturnal Death Syndrome, a brief discussion on who the Hmong are, what their history is, some aspects of their traditional lifestyle, and some of their resettlement problems in the United States will he presented. In addition, an overview of Hmong religion will be given as many of the Hmong concepts about illness and death are tied in with their religious beliefs; therefore some investigations into this area may shed some light on the cause of the Hmong Sudden Unexpected Nocturnal Death Syndrome.

Background Information on the Hmong Ethnic Group

The Hmong are a minority group found in the countries of China, Vietnam, Laos and Thailand. During the recent war in Vietnam, which spread to Laos and Cambodia, the Hmong of Laos were recruited by the American supported Royal Lao government to combat the Russian supported Pathet Lao troops. The Hmong of Laos became known as hard-fighting, loyal soldiers. In 1975, when the United States decided to pull their military and economic support out of Indochina, the Laotian government changed hands. Since many of the Hmong of Laos had supported the Ameri- can war effort in Laos, large groups decided to flee 1.aos rather than chance reeducation camps or possible death under the new Communist regime. The majority of Hmong refugees have relocated in the United States and France. Smaller Hmong refugee communities have settled in Can- ada, Argentina and Australia. Many Hmong of Laos still remain in Thai refugee camps and more keep trickling in across the Mekong river, all hoping for resettlement in a third country.

As the Western world becomes more familiar with who and what the Hmong people are, more attention is being given to their rich and ancient culture. It is unfortunate that there is so little literature on Hmong history. Partly this is because the Hmong did not have a written language of their own with which to document their history until about thirty years ago when a missionary created one for them. The only known historical references to the Hmong are found in ancient Chinese literature.

History of the Hmong

The Hmong as a separate ethnic group were first cited in Chinese literature around 2300 B.C. Southern China was

their earliest recorded homeland. Unfortunately, from the third through eleventh centuries A.D., no direct references to the Hmong can be found in Chinese literature because the literature of that time period referred to all non-Chinese groups collectively as "man" or "nan-man" meaning "barbarians" or "southern barbarians." Starting around the twelfth century, some direct references to the Hmong can again be found. Several references are made to military operations of the Yuan and Ming dynasties against the Hmong, which may have been contributing factors towards the Hmong people moving more and more southward to remoter areas of China (Yih-Fu, 1962).

Chinese suppression of the Hmong continued through the Ching period up through the late nineteenth century. The last large-scale migration of the Hmong appears to have taken place during that time and took them south and southwestward out of China; first into Vietnam, then into Laos and lastly into Thailand. Other reasons for the Hmong people's southward migration may have been overpopula- tion, lack of food, economic disaster, or some combination of these reasons (Yih-Fu, 1962).

Chinese literature refers to the Hmong as "Miao" and others refer to this group as "Meo" or "Hmung." The Hmong prefer the term "Hmong," a word which has come to be interpreted as "free man." At the present time there remains an estimated two million six hundred eighty thousand Hmong in Southern China (Morechand, lkl69), two hundred fifty thousand Hmong in Vietnam (Yang, 1975), five hundred thousand Hmong in Laos (Hang, 1$82), and forty-five thousand eight hundred Hmong in Thailand (Young, 1962).

Hmong Lifestyle in Laos

Wherever the Hmong in Asia live, they remain mountain dwellers as they have been for centuries. Opium is their tra-

ditional cash crop as poppies flourish in upland climates. The Hmong dietary staple is mountain (non-glutinous) rice seconded by corn. Their protein intake level is low, although it is supplied by eggs, chicken, pork and some fish and beef. The rest of their diet is made up of fresh vegetables, fruits and herbs.

Hmong poppy, rice and corn fields are cleared by the ancient slash and burn method. Fields cleared and cultivated in this fashion are usually depleted of nutrients after two or three years of use, and the Hmong must then move on to find new fields. As time passes, crop fields grow further and further away from the village, and eventually village occupants may decide to move their houses closer to thc fields. Other reasons to move villages are superstitious fears of spirits, high death rates of livestock, poor crop yields, or harrassment by other ethnic groups (Chindarsi, 1976). Thus, the Hmong have become known as a people always on the move.

Chinese literature makes references to several subdivisions of the Hmong, examples being Red, Black or Flowery Hmong (Yih-Fu, 1962). These descriptive names probably reflect regional differences in Hmong costumes. However, there are only two major subdivisions among the Hmong of Laos which are demarked by linguistic and cultural differences. They are the White Hmong and the Blue or Green Hmong. The Blue or Green Hmong generally prefer to be called Green Hmong, so they will therefore be referred to as such for the duration of this text. Roth Hmong groups have a strong feeling of being Hxnong, versus being non-IImong. The two groups can understand each other, despite accent, tonal and word differences, and intermarriages are not un- common. One can distinguish between the two Hmong groups by observing their women's style of dress. Jackets and turbans reflect rcgional differences, but in general, the Green TIrnong women traditionally wear dark green, almost black, pleated skirts. The material to make these dark colored skirts is superimposed with light blue batik and brightly colored embroidery. The whit; Hmong womcn

prcfcr hlack trousers and wear plain white pleated skirts for formal occasions.

Both the Green and the White Hmong groups are divided into twenty-three known clans. They are the Cha ("Tsab"), the Chai ("Cai"), the Chee ("Tshib"), the Cheng ("Tsheej") , the Chue ("Tswb) , the Fang ("Faj") , the Hang ("Ham"), the Her ("Hawj") , the Khang ("Khab) , the Kong ("Koo"), the Kue ("Kwm"), the Ltu: ("Lis"), the Lo ("Lauj"), the Moua ("Muas"), the Phang ("Phab"), the Plua ("Plua"), the Tang ("Taj"), the Thao ("Thoj"), the Vang ("Vaj"), the Vue ("Vwj"), the Xiong ("Xyooj"), the Yang ("Yaj"), and the Yao Jua ("Yob Tshuab). However, thirteen of the clans, the Cha, Cheng, Hang, Her, Kue, Lee, Lo, Moua, Thao, Vue, Xiong, Vang and Yang clans, are larger in numbers than the others. Clan ties follow paternity lines and extended family relationships are considered very important. Each clan is divided into many lineages. Mem- bership in a lineage depends upon the ability to track back to a common ancestor. Hmong persons prefer to live with, or near, other lineage and clan members for mutual protec- tion against attacks from other ethnic groups or wild animals. Intermarriage within one clan is strictly forbidden, so sons must SL*~ wives from other clans.

The Hmong are traditionally polygamous and custom re- quires thcm to have many children, preferably sons. After marriage, daughters become members of their husbands' clans and work to help that clan. Therefore daughters are less desired when having children. Sons are bound by custom to care for parents in their old age and to provide necessary funeral services, so are more cherished by Hmong parents. Sons usually bring wives home to live with their parents until they are considered sufficiently mature to start a new household (Chindarsi, 1976). Marriage age is quite early among the Hmong. For the girl the normal age range for marriage is between fourteen and sixteen, and for the boy, between fifteen and twenty. Couples will normally have at least one or two children before considering moving into a home of their own. Even at that time, a son will

typically build his house near his parents' home. The Hmong house is usually built on a mountain slope

and has only an earthen floor. The walls are constructed out of wood and the roof is usually thatched with a special type of hay. The house is usually a large, rectangularly shaped building with two doors and a central pillar. The house is sectioned by walls into two separate areas, the sleeping area and the living and eating area. In the sleeping area, the Hmong bed is usually a simple wooden platform elevated about one foot off the ground. Often whole families will sleep together in one bedroom. In the living and eating area, one lisrially finds a largc fireplace for major cooking, a snlall fireplace to provide warmth and also to act as a sup- plementary cooking area, a guest bed, an eating area, and any spiritrlal altars the family may have.

Hmong villages rarely have any running water or sewage system. Even privies are not commonly built. When it is time to excrete, most simply go out into the surrounding jungle or crop fields and squat among the bushes. Hmong livestock (usually chickens and pigs with occasional ducks, cattle or water buffalo) are allowed to freely wander about the Hmong village and even enter their owner's house. Pigs provide a type of sanitary service by keeping the Hmong house and surrounding areas free from human feces (Chin- darsi, 1976).

Hmong Resettlement in the United States

There are currently approximately forty-six thousand five hundred Hmong refugees resettled in the United States. There are no accurate statistics of the Hmong because United States Immigration does not differentiate between the various ethnic groups of Laos, the Lao, Hmong and Mien. Although the influx of Hmong refugees into Western countries has slowed considerably in the past two years, the Hmong community in the United States is still slowly grow-

ing as more refugees are processed through Thai refugee camps. Although United States policy has been to distribute Hmong and other Indochinese refugees as evenly as possible throughout the individual states, much secondary migration has occurred. The Hmong in particular prefer to follow clan or lineage leaders. Once admitted into the United States, families will save until they have accumulated the money to move to the city where their relatives are located. Thus, large Hmong communities, with a population of three thousand or more, have sprung up in Chicago, Illinois, Fresno, California, Merced, California, Minneapolis, Minnesota, San Diego, California, Santa Ana, California and Stockton, California. Smaller Hmong communities with a population of one thousand or morc exist in Denver, Colorado, Des Moines, Iowa, Portland, Oregon, Seattle, Washington, and Providence, Rhode Island.

Thc Hmong have had a difficult time in adjusting to Western lifestyle. One of the biggest problems is that the majority of Hmong are illiterate, even in their own language. Most other groups of Indochinese refugees have at least a sixth grade education or higher in their own language. However, the Hmong lived in the mountains outside the mainstream of Laotian life and few managed to learn to read and write even the Laotian language, much less any Wcstern language. Due to their limited background in formal education, &any Hmong find it difficult to learn Eng- lish in the classroom setting. Also, the Hmong have very little experience in the use and upkeep of modern American homes and appliances.

Without the ability to speak and understand English, the Hmong are unable to compete for jobs. Since many are unable to read or write, they cannot even understand job announcements or fill in a job application. Therefore, a large percentage of the Hmong have remained in the Wel- fare system. with the threats of Welfare and other assistance cutbacks, many Hrrlnng have grown morc and more fearful and depressed over their future well-being in the United States.

Many Hmong in the United States have clung to traditional practices even though they are living in a new setting. Hmong families remain large and many still live with an extended family. On occasion there may he up to eighteen family members squeezed into a two or three bedroom apartment. At times, this and other Hmong practices have caused neighborhood and community friction.

Despite their many resettlement problems, the Hmong are new Americans and are here to stay. Their culture is an ancient one and has many points of interest. Every effort should be made to understand and learn from their fascinat- ing background and heritage.

Hmong Religion and its Relationship to Hmong Concepts of Health and Illness

The Hmong religious beliefs are closely interwoven with their beliefs on illness and death. It is impossible to discuss their beliefs on illness and death without first reviewing Hmong theology. Unfortunately, it is difficult to present a consistent th~wlogy on Hmong religion. This may be because most of the Hmong religious practices and rituals were traditionally handed down from father to son by observation and word of mouth. As time passed, regional, clan and lineage variations developed.

Different clans often have variations in religious practices, and within one clan lineages may have differences in ritual details. These differences denote which family ties are considered close and which ones are not. Those who follow exactly the same practices and rituals to the last detail consider themselves closer relations.

However, despite the many slight differences and variations, the broad outlines of Hmong theology have some consistencies throughout all Hmong clans, both the Green and White groups. This is because common Hmong traditional

rcligio~is practices are all somewhat centered on ancestor worship. In addition, the Hrnong also believe in many other spiritrlal entities.

Hmong legends explairi the origins of the many spirits the Hrnong believe in. An abbreviated account of these legends will be giver1 as backgror~nd information, becailse the story relates t o Hmong hclicfs orl sickness and health.

Hmong Legends

Long ago, thc chief of gods and his wife, who both lived in the center of heaven, gave birth to two sons. Both sons grcw up and got married. Their wives became pregnant, but the eldest son's wife gave birth first. She gave birth to a great balloon. The chief of gods gave the co~iplc the earth to be thcir home. He told the couple to descend to carth through the gateway between hcaven and earth and there they should burst the balloon. In the balloon would be everything needed to start life on earth. They did as they were told, and when the balloon was burst, all good things came out. All the spirits of nature needed to make earth a good place to livc came from that balloon. Also from that balloon came the ancestors of IImong people today.

When the second son's wife gave birth, she also gave birth to a great balloon, only hers was shaped likc a peanut. l'he chief of gods told them not to burst the balloon, but to burn and destroy it. He then gave this second couple the area of the gateway between heaven and carth to be thcir home. Whcn the couple arrived at their new home, the second son felt strongly that despite what his father had told him, he would burst the balloon instead of destroying it, so that he could see what his child looked like. When he burst the balloon, all manner of evil spirits spewed out. Ogres, evil spirits that cause illness and misfortune, and all wicked things poured out of the balloon. These evil spirits irnmedi- ately attacked the second son and his wife. The wife was

killed, but the second son escaped death by opening the gateway to enter and hide on earth. Unfortunately, all the evil spirits followed him, and this is why evil spirits exist on earth today.

The evil spirits caused such illness, death and misery to mankind that the chief of gods had pity on the Hrnong people and decided to create a special type of spirit to comc to earth and combat the evil spirits. This spirit was called L L neng" and was given special powers with which to fight evil spirits. The first "neng" came to live with a man named Sheeyee. The "neng" taught Sheeyee many healing arts, both how to fight cvil spirits and how to use herbs to heal the sick. However, because Sheeytu: cruelly cracked three dragon eggs, he was cursed by the mother dragon that he would be able to cure all people, but not members of his own family. Because of this curse, when Shceyee's son was taken by cvil spirits, Sheeyee could not win his son's life hack. The death of his son so embittered Shceyee that hc decided to give up his "neng." He also felt that one "neng" was not enough to provide adequate care to meet all the Hmong people's needs. Sheeyee therefore gathered up his healing tools, including his gong, tambourine and rattle, and put them into a pile. hen h e went high up into the skies carrying his howl of holy water. From that high van- tage point Sheeyee poured all the holy water into his mouth. Aiming at his tools he spat the watcr out with great force. The force of the water caused the tools to break up and scat- ter. All those Hmong men and women who were sprayed with holy water, or happened to catch a piece of one of Sheeyee's tools, were those selected to have a "neng." In this way, enough men and women were able to learn the healing arts needed to help sick people.

Plete 1 . Tools o Person with ct "Neng" U s e . Photo by Bobbie Madin.

Types of Hmong Spirits

This legend gives an account of the origins of all the different types of spirits the Hmong traditionally believe in. The Hmong commonly classify the gods into different levels as explained below.

The Great Gods. The two highest levels of gods belong to what are called the great gods. The first levcl of gods include thc chief of gods who lives in the center of heaven and the four gods who hold up the heavens, which for the Hmong are synonymous with the skies. The second level of gods belong to the four gods who hold up the earth and their head god who lives in the center of the earth. These gods are considered benevolent and rarely harm mankind, but can be appealed to for assistance.

The Wild Spirits. The third level belongs to the wild spirits which include the nature spirits, ogres and untamed evil spirits. The nature spirits include a wide variety of spirits ranging from very powerful deities to lesser spirits of localized areas. Some naturc spirits have posts scrving the chief of gods while others of lesser power are thought to inhabit nature spots. The Hmong believe all things in nature are inhabited by a spirit. Thus, mountains, trees, streams, valleys, caves, ponds and even wind currents are thought to be governed by a nature spirit. Nature spirits are not considered malevolent. They usually have little interest in human beings' affairs unless a person offends them in some way. In that case these spirits can cause illness or rnisfort~lnc to the offending person or members of that person's family.

Ogres are considered to be the largest in physical size and the strongest in evil power of all the wild evil spirits. Ordi- narily, it is believed that because of Hmong traditional rcli- gious practices, ogres are prevented from seeing or attacking humans. It is thought that if one worships one's ancestors correctly, one's ancestor spirits will protect one from ogres. If anyone, for some reason, is not protected, it is believed

The Hmong Great Gods

Gods

-- . - . . . - - Gods who hold up eanh

Plate 2. The Hmong Great Gds.

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that ogres can cause instant, sudden death. Wild evil spirits are thought to hide and lurk in the

world, usually in uninhabited areas. They can attack any passerby for no apparent reason, and cause misfortune, illness or death. This is why many Hmong persons prcfer not to travel singly in forests, jungles or uninhabited areas.

The Tame Spirits. The fourth level of spirits belong to what are called the tame spirits. Within this level, the first sublevel belongs to the ancestor spirits. The Hmong believe that each person born has three souls. The first soul is the soul which normally stays with the body. The second is the soul which wanders; it is the wandering soul that causes one to dream while asleep. The third soul is the protective soul which tries to protect its owner from harm. Upon death, the first soul stays with the body at the gravc site. The second soul comcs to live with his or her descendants. The third soul goes back to heaven and may be reborn. A soul may be reincarnatcd as either a person, animal, or perhaps an in- animate object, depending on one's past actions and luck. Thus, the Hmong believe in both reincarnation and that ancestor spirits remain around them.

Hmong dacendants must honor their ancestral spirits by performing appropriate ceremonies and sacrifices period- ically. This is done to insure that one's ancestor spirits will continue to protect and bring prosperity to their family. In addition, if ancestors are not worshipped properly, illness or misfortune may strike the family.

The next sublevel belongs to the house spirits. Each time a Hmong family builds or moves a house, the spirits of their house must be invited to inhabit or reinhahit the house and help protect the family from misfortune. The house spirits consist of two door spirits, one for the front door and one for the hack or side door; four corner spirits, one for each corner of the housc; and two fireplace spirits, one for the large fireplace and the other for the snlall fireplace. In addition, it is believed that the central pillar of the Hmclng house is the resting place for the family's ancestor spirits. Lastly, a

Hmong head of household may choose to set up a family altar to establish a family spirit who will help hring prosperity to the honie and also protect family members frorr~ harm, in which case a spirit will be invited to live in that altar which is usually located in the living and eating area of the Hniong house. Certain ceremonies must be done during cach New Year celebration to keep harmony with all house spirits and to insure that they will continue to protect and assist the family. Ilonse spirits usually do not cause illness to the occupants of the house unlcss they are inadvertently or consciously offended; perhaps by being kicked, hit, or llrinated upon. In that case, sacrifices to the offended spirit may havc to be made to appease that spirit's anger.

"Nengs" are another set of tame spirits. Over the centuries, the Hmong have come to believe that the only way to acquire a "ncng" is to inherit one from an ancestor. It is he- lieved that "ncngs" are passed down through bloodlines. When a person with a "ncng" dies, his or her "neng" will wait until a suitable descendant in the following generation appears. The "neng" will then select that person to be his or her new host. Those who inherit a "neng" have great status in the community as that person is thought to be able to cure illness, foretell misfortune, and ward off evil spirits. Once a "ncng" selects a person, the "neng" teaches that person how to send it back out to talk with, or fight if necessary, the spirits that are causing illness, in order to assist sick persons. Through the "neng" it is possible to communicate with the spirit world and come up with a diagnosis for almost any illness or misfortune. Thus the person with a "neng" is the IImong diagnostician, along with having a selection of othcr healing skills. Some "nengs" arc thought to be very powerful and have a wide range of healing abilities, while others are thought to have only- limited healing powers. However, all "nengs" are spirits whose purpose is to help people and they are thought to prevent the person they select to live with from doing any harm to others.

The last sublevel of the tame spirits contain thc evil spirits which can be captured by some individuals who havc learned

Hmong House Spirits

I . Four house corner spirits

2. Small stovc spirit

3 . Large stove spirit

4. Two door spirits

5 . Ancestor spirits which live in the central pillar

Plate 3. Hmong House Spirits.

A Person with a "Neng"

Plate 4. The Hrnong Diagnostician.

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certain magic spells and rituals. These evil spirits normally have one of two special powers. One power is the ability to cause illness or death to persons by magically implanting foreign objects, such as rocks or bones, into victims. The second power is the ability to cause death through no apparent cause. Some Hmong people say that persons owning this type of evil spirit must cause death to victims in order to satisfy his or her spirit's lust to drink blood. If he or she does not permit his or her evil spirit to drink another victim's blood, the spirit may attack the owner instead.

Hmong Beliefs on Causes of Illness and Types of Cures

Much of the Hmong religious effort is aimed at pleasing or appeasing the various wild and tame spirits. Livestock are not only raised for economic gain and family consumption, but to insure adequate animal sacrifices for planned and unplanned, but necessary, ceremonies. A Hmong family never knows whcn a nature spirit may inadvertently be offended or when an ancestor spirit may require a sacrifice. When a person grows sick, his family will ask a person with a "neng" to tend the sick one. If the person with a "neng" accepts the case, he or she will prepare the altar by burning candles, incense and some gold and silver paper money. He or she will don a black hood, pick up the tambourine and rattle, then sit on a kcnch. While a person behind assists by beating a gong, he or she will start bouncing or jumping up and down on the bench. This causes the tambourine and rattle to make additional noise. Soon he or she enters into a trance. While in a trance, the "neng" is sent to find out from the spirit world what is causing the victim's illness. Some- times the "neng" will discover that it is the time for this person to die and nothing can be done to save this person. This is because it is thought that everyone's time span on earth is predesignated by the gods prior to entry to earth. Before being born, each person receives a "visa" to enter earth. Each

"visa" has an expiration datc. When that datc arrives, the owner of that "visa" rrlrrst die so that he can rcturn to the spirit world.

However, there are many times when the "neng" will find information that can lead to curing a sick person. The types of reasons the Hmong believe cause illness or death are extremely numerous. A few of some relatively common reasons a "neng" may cite for a person falling ill are: l) loss of soul, 2) offended or needing ancestor spirit, 3) angered nature spirit, 4) a wild evil spirit attack, 5) a loved one's spirit attack, 6) a curse, 7) a tame evil spirit attack, 8) an ogre attack, and 9) illness or death by reason othcr than spiritual causes. A brief description of these reasons for illness will be given as examples of how Hmong concepts on illness and death are firmly tied in with their beliefs in spirits.

Loss of Soul. This is considered a very common Hmong malady. It is believed that it is necessary for the soul and body to be in unity, or illness will follow. Usually it is the first soul, the soul that should stay with the body, that gets lost. There are several ways a person can lose his or her soul. One way is that a soul can be frightened away, perhaps by encountering a vicious tiger or a large poisonous snake. When a person becomes suddenly or excessively fearful of imminent death, his or her soul may get so scared that it flees the body. At other times a soul may simply get lost by the wayside when a person makes an extended journey. Another common way a soul gets lost is that when a person passes a place thc soul finds particularly lovely, the soul may decide to linger at that place and forget to come back. The Hmong believe that souls are fond of playing with little knick-knacks and lingering in beautiful nature spots. So, for example, if a person happens to visit a store with many knick-knacks or pass a lovely meadow, his or her soul may cnjoy itself so much playing there, that it will forget to come back to its body.

The symptoms of a porson with a lost soul vary consider-

ably. The most comrnon symptom is a marked behavioral change such as t~ccorning s ~ ~ d d c n l ~ at)r~sivc, dcvc1ol)ing ncr- vous habits, hccoming forgctfr~l, I~cing disoriented, loss of s l~up, or nightmares. If no treatment is obtained, the person may develop physical symptoms such as severe headaches, stomach achcs, body achcs, or weakness of limbs. Victims can grow progressively worse until assistance is found or he or she dies.

l'he treatment for a person with a lost soul is to perform a so111 calling ceremony. This ceremony can be learned by almost anyone. In fact, most Hrnong heads of houschold learn this art. However, in serious illncsscs, most times a person with a "neng" is invited to pcrform the soul calling. Us~ially two or more chickens as well as some eggs and incense are prepared lor the ceremony. The IImong believe souls are fond of chicken meat and eggs as these are considered luxury items in Hmong communities. The cooked chickens, boiled eggs and burning incense are used to entice the soul back to its rightful body. Sometimes the soul calling is conducted in the ill person's home. At other times the soul caller will go to the place it is believed the soul was lost and will then lure the soul back to the village and thc sick pcrson.

Offended or Needing Ancestor Spirit. This is also a very common cause cited for Hmong illness. Most often it is an ancestor spirit who is angry at a descendant for not worshipping or honoring him or her properly, who causes the illness. However, at times, the ancestor spirit is simply lacking something in the spirit world and has come to ask its descendants for what is desired. An ancestor causes illness to a descendant only to communicate his or hcr need. They do not usually cause death unless they are denied their request. The symptoms of a person whose illness was caused by an ancestor spirit are usually physical ones, such as body or stomach pains, fever, or loss of consciousness. Sometimes though, the symptoms are just very bad nightmares.

J':

Plote 5. Alrar of a Person with a "Neng". Photu by Bobble Mortin.

Plate 6. Person with o "Neng' Enter~ng o Trnnce. Pholo by Bubbre Morfin.

The method to cure illness caused by this reason is to consult a person with a "neng." He or she will send the "neng" to talk to. the spirits and gather information. The "neng" will find out which spirit is causing the problem, why, and specifically what thc spirit wants. The "ncng" will even attempt to bargain for the least expensive sacrifice for the family of the ill person to makc. Us~lally the bargain made will be that if the sick person gets well by a specified time, certain sacrifices will be made to the spirit. Common necessary sacrifices arc eggs, chickens, a pig, a cow, a buffalo, papcr money and incense, or any combination of some of these. After performing the sacrificial ccremonics, the family consllmcs the eggs, chickens, or other livestock, so the food docs not go to waste.

Angcred Nature Spirit. Another common diagnosis for illness is an angered nature spirit. It is somctimes difficult to avoid angering nature spirits. A child throwing a rock into a stream may anger the spirit of the stream. A man defecating on a trce root may anger the spirit of the tree. When shoot- ing at a bird, one's arrow or stone may hit an air spirit by mistake. There are countless ways in which nature spirits can be angered. A person with a "neng" can usually find out which spirit is angry, what the offense was, and then bargain with the spirit for the necessary sacrifices needed to appease it. Sacrifices required are usually thosc sirriilar to the oncs made to ancestor spirits.

A Wild Evil Spirit Attack. On occasion, a wild evil spirit may decide to attack sorncone. The attack may be for a variety of reasons. Sometimes the evil spirit is just hungry for human blood. Or perhaps it is a female evil spirit who lusts after young human males. Those who are attacked by evil spirits usually exhibit extreme physical pain, or seem to undergo an cxtreme behavioral change and may appear "crazed ."

A person with a "ncng" must be called in immediately. Thc "neng" will first attempt to make a bargain with the

Plate 7 . Soul-Calling Ceremony. Photo by Bobbie Monin.

Plate 8. The "Neng" Sword Used l o Fight Evil Spirits. Photo by Bobbie Martin.

evil spirit to spare the victim's life in return for sacrifices. The evil spirit may agree to this, but on the other hand, it may decide that it does not wish to relinquish the victim. In the latter case, the person with a "neng" can send his "neng" to fight the evil spirit. If the "neng' is more powerful, thc patient will gain back his health; if not, the patient may die.

In some situations, the person with a "neng" may advise the family of the ill person to perform a ceremony to change the ill person's name. This is done in the hope that the evil spirit will be fooled into thinking the ill pcrson is somcone else and will then leave. sometimes only the first name of the patient is changed. At other times anothcr clan name is borrowed and both the first and clan name are changed. A similar ceremony that Hmong families usually hold to name an infant must be performed for the sick one. Eggs and two or more chickens, or evcn a pig or cow may be prepared to entice the soul of thc sick one to accept its ncw name. After this is done, if successful, the evil spirit will be deceived and the patient recovers.

A Loved One's Spirit Attack. This usually happens when a loved one dies prematurely. That spirit may not want to rclintruish his or her hold on his or her former lover, spouse or children. The spirit may decide to attack and attempt to capture his or her loved ones' souls so that they will die also. In a situation such as this, after discovering the problem, thc person with a "neng" will send his "neng" to try and decoy or deceive the loved one's spirit. Largc paper dolls will be cut to symbolically take the place of the peoplc under attack. The "neng" will then try to fool thc spirit into taking the paper dolls instead of the people's lives.

Curses. A curse is a slightly more rare diagnosis for an ill pcrson. The Hmong believe that curses have power if the person who curses is morally right and the victim has done a serious offense and refused to make amends. A curse can vary in its severity widely. A curse may simply be from an angry parent stating that, "your children will treat yoo as

Plate 9. Hmong Implement Used to Entrap Evil Spirits. Photo by Bobbre Marlin.

cruelly as you treat me." Or a curse may cause economic disaster, serious illness, insanity, or even death.

A person with a "neng" can discern who originated the curse and the victim can only get well if he or she can con- vince the cursing person to withdraw the curse. If the person who originated the curse is already deceased, it then becomes necessary to contact the spirit of the dead person and ask how to make amends and what sacrifices need to bc offered in order to gain forgiveness.

A Tame Evil Spirit Attack. The person with a "neng" may come up with thc information that a person owning a tame evil spirit has sent the evil spirit to implant a foreign object into the victim's body; or is sucking the victim's blood and life away. Victims of this type of attack usually exhibit signs of acute and violent pain and often lose consciousness suddenly. Only a person with the skill to implant foreign objects into a person can take the object out, and thus cure the victim. Only a person with a spirit who has the ability to suck blood from a victim can cure a person being attacked by such a spirit. There may be a contest between two evil spirit owners to see whose spirit is more powerful; or perhaps if an evil spirit owner has been hired to assassinate the victim, or has a personal quarrel with the victim and in- tends murder, the victim's family may be able to bribe him or her into calling off the attack.

Ogre Attack. For victims who exhibit no prior symptoms of ill health and just suddenly die for no apparent reason, the Hmong believe that the victim has died of an ogre attack. Since these deaths occur so suddenly and swiftly, there is usually no time to call in a person with a "neng" for a diagnosis. The Hmong have few traditional defenses from this type of death. They believe that from time to time their ancestor spirits who normally protect them from ogre attacks have let down their guard. Perhaps they have been offended seriously and therefore let the ogres see and attack their descendants.

Illness or Death by Reasons Other Than Spiritual Causes. This is the last type of information a person with a "neng" may give a patient's family. The family must then explore other reasons for the illness or death. Often the family will conclude that the victim must have eaten or drank something wrong. Usually, people who fall sick for this reason suffer from stomach pains, diarrhea, constipation, loss of appetite, loss of weight, nausea or vomiting. When this happens, usually a Hmong herbalist will be called in. These herbalists are skillcd in the use of fresh and dried herbs and have remedies for many sorts of complaints.

Alternatively, a Hmong massager, Hmong accupunctur- ist, or Hmong wiseman may be consulted. Each of thcsc practitioners have various skills in healing a widc varicty of illnesses caused by reasons other than spiritual problems. A IImong massager usually handles cascs who complain of muscular or stomach pains. Hmong accupuncturists use larger needles than their Chinese colintcrparts and arc nsually asked to treat patients with fever or pressure problems. Hmong wisemen are able to read omens, consult Chinese charts and come up with a diagnosis for a wide variety of maladies.

Only those with a "neng" must inherit their skills. Any of the other Hmong healing arts may be learned. Any one person may be skilled in more than one of the mentioned healing arts and may even learn all of the skills. A Hmong person skilled in any of the healing arts, by custom, never advertises his or her skill. The Hmong community learns of thcir abilities only through the village grapevine.

Problem of Hmong Sudden Unexpected Nocturnal Death Syndrome

Starting in 1977, certain mysterious nocturnal deaths among the IImong communities in the United States began to be rcported. As the deaths were scattered throughout

Plate 10 Hmong Herblist in her Gorden. Photo by Bobbie Murtrn.

several different cities, it took about two years before health authorities began to realize that these deaths were starting to fit into a pattern. Whatever was killing these people was reaching epidemic proportions among Ilmong males in the United States. The deaths were not confined to IImong males, however, as Hmong women and Cambodian, Lao- tian and Vietnamese men were also victims of similar deaths. However, by far, the mysterious deaths were striking limong males at a much higher rate than any othcr group. Since medical science has not come up with conclusive evidence as to what caused these deaths, the Hmong cornmnnitics have expressed growing concerns as to their inability to undertake any preventative health care steps. Hrnong men in particular are fearful that they will be the next victim.

Description of Syndrome

The Centers for Disease Control (1981) reported that the deaths shared several common features. All occurred during sleep or while falling asleep. Almost all happened during late night or early morning hours. All except one female case involved relatively young, apparently healthy men. The transition between apparent health and death was very quick. Some witnesses of the deaths reported hearing respiratory difficulties, gasping, moaning, or groaning sounds just prior to death. A few witnesses to the deaths reported hearing gurgling, and observing frothy sputum. Some also reported the victim becoming rigid during the episode, but most remained flaccid. Some victims b t ~ a r n e incontinent of urine or stool, or both. Autopsy findings were of acute cardiac failurc without underlying disease. No signs of toxins or drugs have been found, nor any evidence of suicide.

Some witnesses have interpreted the terminal sounds of moaning, groaning or gurgling as possible signs of terror, indicating that the victim was having a nightmare at the time

of death. There is some speculation that terror from the nightmares could have triggered the deaths (Marshall, 19-81). However, this theory has limited support as the sounds described by witnesses to the deaths are the sounds normally associated with the sounds heard during the end of cardiac arrest cases (Centers for Disease Control, 1981).

Several other controversial causes for the Hmong Sudden Unexpected Nocturnal Death Syndrome have been s ~ g - gested. One is that the deaths arc caused by the long-term effects of exposure to chemical or biological warfare in Laos (Vang, 1982). Another is that the deaths among the Indo- chinese refugee population in the United States are caused by the stress of adapting to life in a new country, or perhaps depression over the loss of their former lifestyle and the inability to be successful in a Western setting (Ota, 1981). It has also been suggested that the deaths may be related to sleep apnca (Munger, 1982). The Centers for Disease Con- trol's research indicates that the cause of the deaths could be a disruption of the cardiac electrical conduction system (Crady, 1982). There are several studies currently being conducted which arc investigating some of these theories, hut so far there have becn no published results.

Centers for Disease Control's Statistics

The Centers for Disease Control (1981) reported forty- one cases of sudden nocturnal death among the nation's In- dochinese refugee communities. Of these, twenty-five cases were Hmong, twenty-four men and one woman. Of the others, nine cases were Lao men, four were Vietnamese men, two were Cambodian men and one was a Mien man. The first reportcd death in the United States occurred on Ju- ly 15, 1977, while the latest death reportcd by the Centers for Disease Control happened on October 2, 1981.

The victims had been in the United States from between five days to fifty-two months prior to their deaths. Seven

deaths occurred in California, seven in Minnesota, four in Oregon and one death each in Washington State, Iowa, Oklahoma, Ohio, Wisconsin, Illinois and Hhodc Island. This somewhat reflects the Hrnong population distribution in the United Statcs.

Thc deaths that werc witnessed occurrcd betwccn nine thirty in the evening and seven in the morning. All died while asleep or falling asleep. There is only one documented case of a survivor of an attack of similar symptoms.

The age range of the victims varies from twenty to sixty- three years of age. By far, the deaths strike those in their twenties and thirties at a much higher rate. The thirties seemed to be the highest risk age range. Twelve of the Hmong men who died were in their thirties. The Centers for Disease C:ontrol qlxoted thc death rate for sndden nocturnal death of adult males from 1,aos betwen the ages of twenty-five to forty-four as eighty-seven per one hundred thousand. This includes men horn three ethnic groups of I,aos, the Hmong, the Lao and the Mien. This death rate is comparablc to the sum of the four leading natural causes of death among United States men of similar age.

For F-Imong males alone, between the ages of thirty and forty, the death rate for sudden death soars to two hundred per one hundred thousand (Munger, 1982). This translates to a truly epidemic problem for Hmong males in the United Statcs.

Implications of the Deaths

The IImong in the United States are still a close knit group despite their wide flung locations across the con- tinent. As the number of deaths mount, the Hmong community is growing increasingly alarmed, especially as many claim they know of additional sudden noctilrnal deaths that havc not been documented by the Centcrs for Discasc Con- trol.

Y~lung Hmong males are having enough adjustment problems just learning how to cope in the American system. From being a mountain farmer or soldier with little or no education, the Hmong male is now expected to quickly learn English, find housing for his family, find food and medical care, find schooling for his children, and find a job to support his large extended family. Most IImong men are also having diffic~ilties learning to cope with a change in their role and status in the community. In Laos, the Hmong head of household commanded respect and unquestioning obedience from every member of his household. In the Western setting, the Hmong male must now cope with the concept of equal rights for women. He is often surprised and dismayed when his wife or children begin to question his actions or decisions. In addition, the Hmong head of household who once provided adequately for his family in Laos must now accept being on the bottom of the American socio-economic ladder. All of this upheaval and change causes a great deal of stress and at times Hmong men may wonder if it is worth the effort to try to assimilate themselves and their families into Western life. Now that they arc faced with the added stress of fear of sudden noct~irnal death, rnany IImong males rriay be even rnore do11btf111 that the struggle to he sr~ccessul in their new environment is worth it. This may he a contrih~~ting factor to sorne Ilmong rnales continr~ing t o keep thcir farr~ilies in the Welfare system.

Another repercrission of thesc sudden noctrlrnal deaths is that the deaths arc: callsing a great deal ol fear a r~d superstitious beliefs among Ilmong refugees still in the Thai refugee camps. lhmors and wild stories regarding thcsc deaths have spread anlong some camp residents. One story is that the sudden nocturnal deaths are caused because the refugces are not allowed to practice their traditional rcligion in the Uni~ed States. This causes ancestor spirits to get angry and thcsc spirits cause the sudden nocturnal deaths. Another story is that because the United States is on the other side of the world, it must be that the United States is whert: ogrcs

live. Many refugees are afraid to enter the United States for fear they will soon he killed hy ogres, despite repeated reas- slxrances f r o ~ n relatives and friends now living in the United States that this is not so.

Ilesearcl~ has not yet narrowed the scope of possible reasons for the Hmong sudden nocturnal deaths. As long as this is so, IIrnong and other Indochinese groups will live in fear that they or their family ~nerrlhers will he the next victims. 'I'he IImong do not know what preventative health mea- sures they should adopt; rior does Western scie~ice know how to screen for high risk victims. Study of this r~nr~sr~a l syndromc is vitally necessary, not only to help the IImong, 111xt to add needed knowledge to the field of cross-cultural medicine. Altho~xgh the Ilmong have the highest death rate, other ethnic gro~lps suffer from similar sudden nocturnal death syndromes, h r~ t at a lower rate of incidence. Japanese, Filipino and other Indochinesc ethnic grorrps all share an interest in obtaining more information on Hmong Sudden Unexpected Noctnrnal neath Syndrome.

Focus for Study

'This book foc~ised only on possible cult~xral reasoris in- flr~e~lcirig thc high rate of sudden nocturnal deaths arnorig the Hmong population. The author did not propose to (lo any mcdical laboratory studies as others were already pllr- wing investigations into thcse areas. Although it was known that thc deaths were related to a rnalfunction of ~ h c heart, there was still a need to discover why certain individ~~als 1,ceamc sudden nocturnal dcath victims at certain times in their lives. It was thought that investigation into social and c~l l t~lral aspects of the s~xdden nocturnal dcaths could throw somc light on the cause of this syndrome.

The Hmong thcmst:lves have several views on what is caw- ing the srldder~ nocturnal deaths. Western medicine tt:nds to discredit alternate health services delivery systems. How-

ever, the IImong have hecn delivering health care to themselves in a fashion they fccl Inore than adequate for as rriany centr~ries as they can remember. Accnpuncture, herbal lore, chiropractic and othcr controversial rr~edical disciplines have now gained widespread acceptance in the Western world. perhaps aspects of traditional Ilmong health dcliv- ery systems will cvcr~tr~ally find acceptance also. Iiathcr than ignoring the possibility that the Hrnong rriay have an answcr to the c~rlcstiori of what is causing suddcri ~locturnal dcaths, an investigation was made to see whether the Hrnong hcliefs on the subject were pla~lsihlc. Rather than ridicclle the Hrnong beliefs in nature and ancestor spirits and sudden noct~irnal death caused by ogres or curses, a study was first dnnc to see if thosc beliefs could have affected the health status of some or all of the sudden noctr~r- 11al dcath victims.

In addition to strldying the IImong beliefs on thc causes of sudden nocturnal dcath and whether these hcliefs co~ild affect the sudden nocturnal death rate, research was also conducted on certain aspcots of the Hrriong c~llturc which could also possibly have been contrib~lting factors to the high rate of IImong s1lddc11 noct~lrnal deaths. For example, cornrnon past geographical locations, job occ~ipations, refrlgce camp experiences, housing, use of opiurn or othcr drugs, and co~ri- tnon hobbies were reviewed. Other possibilities examirled were whether the dcaths were linked to certain individual's diets (cons~lrnption of special foods), or were perhaps related to the risagc ol traditional medicines or health treatments, and also whether thc deaths wore related to rricrri- hership in certain clans or lineages. l'hc field of c~iltural investigation was very wick However, the author investigated as many aspects of Ilmong cultlire i11 relationship to sudden nocturnal dcath, as was possil-)lc within thc: scope of the str~dy.

This invcstigation did not confine itself to only those cases reported by the Centers for Disease Control. The study included sevcral undocumented and sllspectcd cascs as it was felt in a cultural study, the larger the number of cases, the better the chancc of gathering more information. In addition, the study did not want to focus only on slidden nocturnal deaths of thc Hmong in the United States. Therefore, any sudden noctl~rnal death cases of Hmong from othcr countries, such as Canada, France, Laos or Thailand, that thc author discovered, were included in the st~ldy.

CHAPTER 2 Review of Previous and Current Research

on Hmong Sudden Unexpected Nocturnal Death Syndrome

The phcrlornenon of Hmong Sudden Unexpected Noctur- rlal Ileath Syndrome is relatively new in the United States, particularly as the Hrrlong have been living among us only since 1975. Doc~~merltution of these mysterious dcaths began a Inere five years ago. Perhaps due to the limited time period of exposure to this ~lnusual syndro~ne, there seems to be very little literature on past studies of Hmong sudden nocturnal deaths. As stated earlier, there are several investigations currently being conducted, but to date, no one has published or disclosed their results.

However, a review of the literature reveals that during the 1940s and 1950s some strldies on similar sudden nocturnal deaths anlong the Filipino poprllation of Ilawaii u7erc donc. 'l'hesc Filipino deaths had many sirriilarities to the Hnlong sudden nocturnal dcaths. Rt:view of tho studics done on Fili~lino srlddcn nocturnal deaths rriay prove relevant to the current investigations on Hmong sudden nocturnal deaths. Unfortunately, even the Filipino sudden nocturnal death st~ldics are limited in number and scope.

Despite the liniitations of literature available on the subject, a review of the current studies boing donc on FImong sudden noct~lrnal deaths and past studies on the Filipino sudden r~octnrnal deaths reveals a wide range of theories as to the possible cause for the sudden nocturnal death syn- dromcs. Some theories are exotic in nature and little support can he found for them, although thcy cannot be disco~lnted l~ntil further research is done. Other theories are less spcou- lative in nature, although evcn these lack adequate support-

ive evidence. The causc for Hmong slidden nocturnal deaths remains a mystery and rr~ore research into all possible aspects of the deaths should be done until conclusive evidence of the disease causc and possible cures can he found.

Current Studies on Hmong Sudden Nocturnal Deaths

During the past two years, the news mcdia has given ever widening pliblicity to the subject of Hmong sudden nocturnal deaths. This has generated more interest on the subject and encouraged more research on Hmong sudden nocturnal deaths to get underway. Each of the c~lrrent studies has a different perspective and thcrc continue to he widely varying theories on thc cause of the these deaths. At this time, it is impossible to guess which avenue of research will produce the most fruitful results, especially as no one has yet published their findings. Each investigation has merit in its own right and it is beneficial that there is very little duplication of research arcas bctwccn the current studies, despite thc fact that the research is ccntcrcd on a common subject. The current studies will be briefly mentioned on the following pages.

Centers for Disease Control

Doctor Roy I k o n of the Centers for Ilisease Control in Atlanta, Georgia, is heading a nationwide study on the sudden nocturnal death syndrome among the Indochinese populations. He has found that the deaths are compatible to cardiac dysrhythmia, hut the underlying cause has not yet been established. A possibility is that the hearts of the sudden nocturnal death victims underwent loss of timing due to a faulty transmission of electrical signals. What causes the faulty transmission and why it happens only during sleep

has not been discovered yet. Besides examining heart tissues, the Centers for Disease

Control has also run routine toxicologic screening tests on thirty cases of sudden nocturnal death. No evidence of toxins were found in the victims. In addition, they have circulated a questionnaire to study twenty-six cases of sudden nocturnal death from the country of Laos to determine whether the doaths might be associated with geographic regions of Laos, current or past job occupations, military experience, chronic stress, refugee camp experiences, or dietary changes (Centers for Disease Control, 1981).

Only prdiminary reports from the Centers for Disease Control's study are now available for public perusal. Doctor Baron has stated that he believes they will havc some an- swers soon, but will not disclose any further information until the studies are complctcd (Grady, 1982).

Prendergast

Doctor Thomas Prendergast, an epidemiologist in Orange County, California, where a large population of Hmong live, has examined more than eighty Hmong elcctrocardio- grams to see if he could uncover any heart problems in the Hmong community. He found no abnormalities in the electrocardiograms to account for the high rate of sudden nocturnal deaths among the Hmong. However, his tests lasted only a few minutes each and he suggests that longcr testing could perhaps disclose some significant disturbances (Grady, 1982).

Westermeyer

Doctor Joseph Westermeyer, a professor of psychiatry at the Univcrsity of Minnesota has studied the Hmong in his mental health clinic. He proposes that the sudden nocturnal

deaths may be linked to the stress of cllltural assimilation. Many Hmong and other refugees have experienced difficulties in adjusting to their loss of native homeland, lifestyle, religion and relatives. Westermeyer attributes widespread depression among the IImong related to their loss of social networks and forced transition from a spirit-worshipping, agricultural society to an urban, Western lifestyle. In addition, nnemployment and dependency on Welfare disrupts the normal self-image and independence of the Ilrnong pco- ple (Ota, 1981). Wcstermeyer reports that the Hmong seem to have an unusually high number of nightmares, reflecting that the Hmong are a trollbled people under stress. Other studies have shown that people under stress are more likely than othcrs to develop cardiac arrhythmia (Grady, 1982).

Munger

Honald G. Munger, doctoral candidate at thc University of Washington in Seattle, Washin~qon, has compared Hrrlong sudden nocturnal deaths with Filipino sudden nocturnal deaths in Hawaii. He noted some striking similarities between the two syndromes. In both syndromes, the deaths wcrc associated with sleep. The age and sex distribution of the victirns were similar. Both the Hmong and Filipino sudden noctr~rnal death rates peak in the twenty-five to thirty- five year old groups. Both syndromes are consistent with death due to cardiac arrhythmia with no apparent underlying cause. Munger suggests that the most promising area of research concerning these deaths would be the study of disorders of respiration during sleep, known as the sleep apnca syndromes (Munger, 1982).

Munger is currently conducting additional research on Hmong sudden nocturnal deaths. He will conduct a field study in the Thai rcfugcc camps to see whether any relevant factors indicating the cause of Hmong sudden nocturnal death can be found thcrc (Munger, 1982).

Marshall

Eliot Marshall reported the theory of a national expert on unexplained sudden deaths that the Hmong perhaps suffer from a congenital weakness of the antonomic system that causes the heart to heat irregularly and fibrillate in mo- ments of intense emotional stress. IIu speculates that this weakness may be due to inbreeding (Marshall, 1981).

Stanford Sleep Center

This center is attempting to study the only known survivor of a sudden nocturnal death attack, Ge Xiong, a thirty- six-year-old Hmong male formerly of Seattle, Washington. One night during December of 1980, Ge Xiong's wife awakened to hear muttering and respiratory distress coming from her husband. Ge Xiang's skin had turned bluish and there was some froth in his mouth. He could not be aroused, although his eyes were open. His life was probably saved due to the speedy arrival of a paramedic team. The team found Ge Xiong's heart stopped, but were able to restore the heartbeat. Ge Xiong spent ten days recovering in a hospital, the first five days of which he remained unconscious. After recovery, he srihsequently moved to Fresno, California.

The Stanford Sleep Center, which specializes in the study of sleep disorders, would like to monitor Ge Xiong's breath- ing, eye movements, brain waves and heart rhythms during his sleep. It is hopeful that arrangements can he finalized for this study as this could provide some valuable information ahout the sleep patterns of the Hmong (Xiong, 1982).

Bliatout

Ge Xiong's survival was attributed to the speedy arrival of a paramedic team who quickly put him under cardiac

monitoring. It was felt that if future victims of sudden nocturnal death attacks could also be kept alive until paramedic teams arrived, perhaps more people could be saved (Schade, 1982). It was suggested that widespread teaching of cardio- pulmonary resuscitation techniques to the Hmong communities might possibly help keep Hmong victims of sudden nocturnal death attacks alive long enough for trained per- sonnel and cardiac monitors to arrive.

Through funding of the Multnomah County Health De- partment, under the direction of the author, the Hmong Family Association of Oregon is conducting a study to see if teaching cardio-pulmonary resuscitation t t~hniques to the local Hmong community might reduce the death rate caused by Hmong Sudden Unexpected Nocturnal Death Syndrome. So far, two hundred Hmong adults have been trained in these techniques. Since the inception of the program, there has been no reported attack of sudden nocturnal death. It has therefore not been possible to measure the success of the program.

Studies on Filipino Sudden Nocturnal Deaths

There were at least forty-five documented cases in IIa- waii of Filipino sudden nocturnal deaths, or what is called, "bangungut." In the Filipino cases, previously healthy males died during the night making moaning, snoring or choking noises. "Bangungut" means nightmare in Filipino and reflects some theories that the mysterious deaths were caused by terror during a nightmare. Due to the similarities of the two syndromes, a brief review of studia on the Fili- pino sudden nocturnal deaths will be given.

Manalang

In 1948, Doctor C. Manalang from the Department of

Health in the Phillippines conducted a study on Filipino sudden nocturnal deaths in Hawaii. He proposed that victims, after eating a large meal and falling aslcep, developed a violent dream. This then caused a sudden excess reaction of the heart which overworked and caused a stasis in the lungs. This would produce the choking and groaning sounds associated with the syndrome, thcn sudden death from lack of oxygen (Manalang, 1948).

Larsen

In 1955, Doctor Nils P. Larsen, a prominent Honolulu pathologist, also studied the Filipino sudden nocturnal death syndrome. He proposed that these unexplained deaths were caused by excessive fear during sleep, probably due to a nightmare. Larsen found no consistencies in post-mortem examinations and chemical analyses, causing him to theo- rize other reasons for these mysterious deaths. TIe cited pre- cedences for acceptance of exotic deaths, such as death caused by voodoo and death caused by the Hawaiian coun- terpart of voodoo-being "kahunaed" (Larsen, 1955).

Nolasco

In 1959, Doctor J.G. Nolasco of the University of Manila investigated the possibility that Filipino sudden nocturnal deaths were linked to the consumption of a toxic material found in one of the fish products commonly eaten by the Filipinos. Although a potent vaso-depressor capable of causing death in a manner consistent with sudden nocturnal death syndrome symptoms was found in large enough con- centrations in some preserved fish products dommonly consumed by Filipinos, not all victims had eaten fish or fish products the day of their death ("Bangungut", 1959).

Investigation on Chemical Warfare in Laos

One of the most controversial hypotheses on the causes of Hmong sudden nocturnal death is that these deaths are relatcd to exposure to chemical warfare in Laos. Some think that perhaps thcrc is a lingering biological effect due to ex- poslire to chcmical warfare in Laos which predisposes some individlxals to sudden nocturnal death at a latcr time.

U.S. Army studies have shown that three known types of lethal chemicals were used in Laos. One was a nerve agent, the second was a blistering agent, and the third was a suh- stance that induccs hcavy bleeding. It is believed that the chemicals were slipplied to Communist forces in Laos by the Soviets.

The Carter administration refused to acknowledge the use of lethal chemical agents by the Soviet-backed regimes of IIanoi and the Pathct Lao. During the Reagan administration, up until March, 1982, the United States State De- partment maintained the position that thcrc was no conclusive evidence that gassing had occurred, or was occlirring in Laos.

On D~ucmber 12, 1980, the United Nations General As- sembly adopted a resolution calling for an United Nations investigation into the use of chemical warfare in various parts of the world. This included examination of many reports of chcmical gassing in the country of Laos and a field visit to refugee camps in Thailand.

The united Nations' Report to the Secretary-General on Chemical and Bacteriological Weapons, dated November 20, 1981, stated that there was no reason to doubt the integ- rity of those persons making allegations of chemical warfare attacks in Laos. However, it was reiterated several times that the testimonies of individuals was not enough to prove that such attacks were actually occurring. Despite the evidence that was produced, the United Nations' report claimed that the study was inconclusive because members of their team were not allowed into areas allegedly sprayed

with chemicals to collect samples in a scientific manner. However, this report does reveal some interesting testimony and information. It states that witnesses claim that exposure to chemical clouds allegedly sprayed in Laos caused in rapid sequence,

. . . dizziness, nausea, coughing of bloodtinged material, choking, vomiting of massive amounts of blood, t~loody diarrhea, formation of multiple small hard blis- ters, followed by shock and death in those directly under thc sprays. For those on the periphery of the attacks, or who ate or drank contaminated food, or water, symptoms took longer to develop (days, rather than minutes to hours) and usually led to death within two weeks if no treatment was given.

After evaluating these symptoms, experts concluded that no known traditional chemical warfare agent alone, or in combination with others could cause the above effects. Upon analyzing a leaf and stem sample allegedly from an area that had been under a chemical attack, three potent mycotoxins of the trichothwene group were found. Tricho- thecenes are capable of producing the symptoms seen by Hmong and other witnesses (United Nations General As- sem bly, 1982).

Despite the reluctance of the United Nations and the United States government prior to March, 1982, to admit to chemical warfare going on in Laos, Hmong military leaders estimate that a large percentage of the Ilmong refugees in the United Statcs have been exposed to chemical warfare, either knowingly or unknowingly in the past. Growing numbers of Hmong people are beginning to suspect that prior exposure to thesc unusual chemical gassings or their residuals weakened them in some way and makes them more susceptible to sudden nocturnal death.

Besides the problem of sudden nocturnal death, there are many Hmong in the United Statcs who are chronically ill. Some believe that the cause for these chronic illnesses also

lies with prior exposure to chemical warfare (Hamilton- Merritt, 1981). There is currently no national study to investigate the chronically ill Hmong to see if these allegations have any basis, nor is there any study being done to see if the Hmong sudden nocturnal deaths could be linked to prior exposure to chemical gassing. Perhaps there is reluctance to undertake such a study because there are many claims that sudden nocturnal deaths occurred in the Hmong population prior to the beginning of the gassing, and therefore it would seem unlikely that the deaths are related to exposure to chemical warfare.

In response to this, some IImong military leaders have stated that they believe that chemical warfare began in Laos as early as 1954. Unfortunately, there is no documentation of sudden nocturnal deaths prior to that year. This is because the Hmong did not commonly utilize medical facilities in the cities where medical records might have been kept, nor did they have a written language prior to the 1950s. Some elder Hmong persons state they have heard about cases of sudden nocturnal deaths prior to 1954 while other insist adamantly that there were no such deaths before the war years, There seems to be some confusion between death caused by diphtheria and sudden nocturnal death among some Hmong groups. This makes it even more difficult to ascertain whether these nocturnal deaths have occurred in the Hmong population throughout its history or whether it is a recent phenomenon.

The controversy over the thtwry that sudden nocturnal deaths are caused by prior exposure to chemical warfare is likely to continue until more research into the types of chemicals allegedly being used in Laos and their short-term and long-term effects is conducted. Until this happens, we cannot discount this theory. Whether this theory is proven or disproven, research on this subject would not only benefit the IImong and other ethnic groups who suffer from sudden nocturnal deaths, hut would be aseful information for our military and national security.

Discussion of Studies

Each of the current studies being conducted on sudden nocturnal deaths has considerable merit in itself. Of course, each study must have some limitations depending on its scope and focus. For example, Doctor Baron of the Centers for Disease Control has already stated that he does not feel that the sudden nocturnal deaths are related to exposure to chemical warfare. He has, therefore, concentrated his investigations on hcart tissue analysis accompanied hy intcr- viewing the families of the deceased for common backgrounds. In addition to narrowing the scope of investigation, the Centers for Disease Control did not inclllde all the Hmong victims of sudden nocturnal deaths in their study. The author knows of two Hmong males in Hawaii and onc Hmong female in Richmond, ~al ifornia, who were not included on their list. Another factor to consider when reviewing the Centers for Disease Control's study on sudden nocturnal death is that it does not give enough emphasis on the much higher risk of these deaths for Hmong men. Thc focus of their research is on sudden nocturnal deaths among Laotians as a whole, rather than concentrating on the ethnic group of the Hmong. Therefore their statistics reflect the lower death rates of the Laotian group as a whole, which downplays the skyrocketing death rate figures of the Hrnong.

Prendergast's study was designed to be very narrow in scope. IIe worked only with the Hmong living in thc Orange County, California area, and his test consisted only of a short clectrocardiogram . Longer electrocardiograms and other more comprehensive testing should be considered for futurc investigations a. well as including Iimong populations in other cities in the study.

Wcstcrmeyer's theory that the deaths are related to the stress of cultural assimilation has already come under attack by Larry Judy, a Public Health Service epidemiologist working for the Minnesota Ilealth Department. IIe stated that not all the suddcn nocturnal death cases were depressed

people (Ota, 1981). Although this may seem to be the case on the surface, consideration should be given to the fact that Hmong refugees living in the United States have lived through many years of war, suffered loss of homes and relatives, and are now thrust into an extremely different lifestyle. Although some of the IImong victims may not have appeared to be depressed, the stress level must have been very high in their lives. Westermeyer is currently seeking funds for further investigation of this theory as more research into this area is definitely needed.

Munger has shown several similarities between Hmong and Filipino sudden nocturnal deaths. It is unfortunate that since the Filipino sudden nocturnal deaths occurred during the 1940s and 1950s, no extensive studies comparing Hmong and Filipino sudden nocturnal deaths can be done at the present time. Munger has only just begun his field study among the Hmong refugees in the Thai refugee camps. It is hoped that he will come up with some significant findings.

Marshall's report that sudden noctl~rnal deaths could be relatcd to congenital weakness due to inbreeding has little validity. Hmong custom severely prohibits incest. Not only are I-Imong males not allowed to marry close relations, they are not permitted to marry any female in thcir clan, no mat- ter how distant the relationship. Marriage between brother and sister's children, and sister and sister's children are allowed a? girls marry into other clans and their children bear that clan's name. However, even these marriages are not extremely common. It remains possible that Hmong sudden nocturnal death is a problem related to genetics but most likely not caused by inbreeding.

The study on Ge Xiong proposed by the Stanford Sleep Center has had problems getting underway. There are apparently funding problems and difficulties in arranging suitable testing times. Hopefully, these problems will be worked out as this would bc the only study related to a possible relationship between Hmong sudden nocturnal deaths and the sleep apnea syndromes. It is also hoped that as time passes other survivors of sudden nocturnal death attacks can

he found. A study sample of just one person is very limiting. The author's own program to teach the Hmong commu-

nity in Portland cardio-pulmonary resuscitation techniques is designed to help prevent future sudden nocturnal deaths, not to study possible causes of the disease. The author feels all Hmong communities throughout the United States and other countries should be encouraged to start similar train- ing programs, as this is a practical way to help prevent death. However, efforts in this direction will not uncover the cause for sudden nocturnal death.

The theories on the causes for Filipino sudden nocturnal deaths, although of interest, have some shortcomings. Manalang and 1,arsen felt the deaths were triggered by violent dreams. Since the Centers for Disease Control has explained that the moaning and groaning sounds often heard by witnesses are normal terminal sounds heard during cardiac arrest, this theory cannot be considered a likely one, either for the Filipino or Hmong sudden nocturnal death syndromes. Nolasco felt there could be a relationship between the Filipino sudden nocturnal deaths and the consumption of certain fish or fish products. Although many Hmong families also consume similar fish and fish products as the Filipinos did, it has already been shown that not all the Filipino sudden nocturnal death victims had consumed fish or fish products. Therefore, this theory is also unlikely to be proven as the cause for Hmong sudden nocturnal deaths.

As stated earlier, there is little research being done about the effects of gas attacks on the Hmong. The United Na- tions' study was to find out if allegations about the usage of chemical and biological warfare in Laos and other countries were true or not. The study did not do an in-depth study about the effects, either short- or long-term, on the victims exposed to the chemicals. The Centers for Disease Control continues to state that there is no clinical evidence to support a poisoning hypothesis. However, this does not rule out the possibility that a toxic substance is a possible cause of death. Only routine toxicological tests have been done, but

no detailed chemical analysis. More research in this area must bc encouraged rather than discounting the theory that exposure to chemical warfare predisposes some individuals to snddcn nocturnal death.

CHAPTER 3

Methodology and Materials

This investigation examined several hypotheses regarding the relationship between some aspects of Hmong culture and the IImong Sudden Unexpected Noctllrnal Death Syn- drc~rne. Information was gathcrcd from Hmong commoni- ties throughollt the united States, Thailand, Canada and France. Emphasis was given to studying cultural aspects of the Hrnong sudden nocturnal deaths, but other aspects of the deaths were not ignored. This study did not want to pre- clude other theories on the subject. On the contrary, it wished to encourage more research into all possible causes of sudden nocturnal deaths. Each investigation, by necessity, must focus on only certain aspects of a problem. Thc focus selected for this study was on the possible relationship between Hmong traditional beliefs and practices regarding health, illness and death, and several other aspects of Hmong cnlturc, and the Hmong sudden nocturnal deaths.

Hypo theses

Five major hypotheses and various related subject matters were examined in this study. Each of the five hypotheses covcrcd an aspect of Hmong culture that the author felt could possibly be a contributing factor to the high rates of sudden nocturnal death among the Eimong people. In addition, some miscellaneous theories put forth by other invcsti- gators werc also briefly considered.

Hypothesis One-Hmong Religious Beliefs

The first hypothesis of this strldy was that Hrrlong traditional bclicfs about illness and death were contributing factors to the IImong Sudden Unexpected Nocturnal Death Syndrome. Strong beliefs can affect a person's health status and can even cause death in some instances. For exarriple, Larsen (1955) citcd a case of a Hawaiian man dying because tie believed a rival for the affections of his girlfriend had paid a Hawaiian priest, a "kahuna", to chant him to death. Although the patient was confined to the Queen's Medical Cknter, a large and well-equipped, modern hospital in Honolulu, Hawaii, no apparent diagnosis could be found. Shortly thcrcafter, the patient died as he had said he would. Aotopsy revealed nothing organically wrong.

1Imong elders cite rriany examples of similar rriysteriorls deaths which they believe were carlsed by ogres or evil spirits. A1thongt:h Western medical practitioners may ridicule these concepts, generations of belief in supernatural powers can cause ill health and death. Many Hmong elders have stated that they believe that the IIrnong sudden nocturnal deaths were caused by people not continuing their traditional religious practices and rituals to worship their ancestors. Thcy fccl that in anger over not being worshipped properly, ancestor spirits may withhold their pro- tection and this allows ogres and evil spirits to kill their descendants. It is their belief that ogres arc the spirits that cause sudden nocturnal deaths.

The disruption of the Hrnong traditional religion is caused hy several factors. One factor is that some Hnlong have converted to some form of Christianity. Another factor is that the recent war killed many heads of household before they could teach their sons the proper methods of ancestor worship. 111 addition, due to the uncertainty about United States law, many Hmong are fearful of performing their ceremonies which can he protracted and noisy. Some IImong families who attempted to perform traditional ceremonies were visited by the police and warned to cease dis-

turbing the peace. Othcr families have had their animal sacrifices confiscated by public health officials.

Since the belief that the sudden nocturnal deaths were related to the disruption of traditional religious beliefs on ancestor worship is a somewhat common feeling among many Ilmong, especially the elders, the author decided to study the deceased's religious backgrounds to see if those who converted to Christianity suffered higher death rates than those who had not. In addition, the families of the dt~eased were reviewed as to beliefs on the cause of death, to see what percentage believed the deaths to be related to aspects of Hmong religion, such as whether they believed the deaths were caused by ogres, evil spirits, ancestor or other spirits, or the inability to perform traditional ceremonies. It was felt that this would uncover how large a percentage of the Hmong community believed in the power of death or illness caused by spirits angered by the inability of descendants to continue their traditional religious beliefs, practices and rituals. If the percentage was large, it would indicate that traditional religior~s beliefs did contribute to the stress level, mental health status, and general health status of many TTmong people and perhaps was a contributing factor in the sudden nocturnal death cases.

Hypothesis Two-Utilization of Traditional Health Practiws

The second hypothesis was that the inakility to find and use traditional Ilmong healing arts caused deterioration of health and eventlially was a contributing factor to the IImong Sudden Unexpected Nocturnal Death Syndrome. Ilmong communities across the United States have reported the inability to find and use their traditional medicines and healing arts. There are many reasons why this is a problem for the Hmong society in Western conntrics. First, the IImong communities in Western countries are new commu-

nities. Many families did not know each other back in Laos. Since it is the custom that Hmong healing practitioners not advertise their skills, it was difficult for newly arrived refugee families to find the right type of healing practi- tioner. Second, many healing practitioners were linable to bring their tools of trade with them. Some were forced to sell them when faced with starvation in the refugee camps. Others were prevented by immigration officials from bring- ing in their plants and herbs. Last, due to the disruption of IImong society caused by the war and the necessity of relocation, many of the Hmong youth have lost knowledge of thcir cultural background. It now seems that only a few of the elders still retain knowledge of Hmong medicine and healing arts; and as these people die, the arts will slowly be lost.

There is an overwhelming number of Hmong adults who have expressed to their community leaders or tb the author the feeling that Western medicine is unable to cure the types of sickness Hmong people commonly have. Part of this problem is caused by language barriers, economic problems, transportation problems and lack of information as to where to find medical help. However, more importantly, there seems to be a cultural barrier between the Hmong clients and Western practitioners of medicine. A Hmong client's expectations of a doctor's treatment are very different from what they usually get. The Hmong often explain the symptoms of thcir illness in ways that western doctors may not understand or accept, even when a translator is present.

It seems that the Hmong are finding it increasingly difficult or impossible to continue utilizing I4mong traditional healing treatments, but are not yet ready to utilize Western medical delivcry systems. Since so many Ilmong have expressed their concern over these problems, the author decided this would be a worthwhile subject to invcstigatc.

Hypothesis Three-Hmong Subgroups, Clans and Lineages

The third hypothesis was that membership in certain Hmong subgroups, clans or lineages was a contributing factor to the Hmong Sudden Unexpecttd Nocturnal Death Syn- drome. As stated earlier, the Hmong of Laos were divided into two linguistic and cultural subgroups, the White and Green Hmong. The author investigated whether sudden nocturnal deaths struck one subgroup more than another. Also investigated was whether sudden nocturnal deaths pro- portionately struck certain clans more than others, or whether certain lineages suffered more from these deaths. If this hypothesis were found to be true, it would suggest that therc was a relationship between sudden nocturnal dcath and genetics.

The Centers for Disease Control (1981) stated that only one of their cases alleged a relative also dying from sudden nocturnal death, the death taking place in Laos. However, the author knows of several other cases in which relatives also died from sudden nocturnal deaths. One of the cases involved a father and son who both died sudden nocturnal deaths just months apart from each other. These deaths occurred in the state of California. Another case involved three cousins who all died sudden nocturnal deaths. Cases such as these suggest that investigation of this hypothesis could be a promising avenue of research.

The author wishes to note that many Hmong have more than one name and some entered the United States with a name that does not reflect their true clan heritage. As the author is familiar with the Hmong language and people, he is well-equipped to investigate to which subgroup, clan and lineage cach victim really -belonged, which was important when checking into genetic background.

Hypothesis Four-Past Geographic Locations

The fourth hypothesis was that past geographic locations were a contributing factor to the Hmong Sudden Unex- pected Nocturnal Death Syndrome. First considered was that IImong people from different regions in I,aos have slight cultural differences. In J,aos, there were four regional Ilmong subgroups whose slightly different costumes were indicative of some minor cultural differences. They were the Hmong of Sarn Neua, noted for their blue striped sleeves; the Hmong of Xieng Khouang and Borikane, noted for their pink and green cummerbunds; the IIrnong of Saya- hory, h a n g Prabang and Vientiane, noted for their blue bordered aprons; and the Hmong from Phongsaly and 1,uang Nam Tha, noted for their embroidered aprons. If certain Hmong groups from the same region of 1,aos were found to havc higher numbers of sudden nocturnal death, it wollld indicate two possibilities. The first would be that these dcaths were related to genctics as people in one rcgion tend to intermarry and keep the genetic pool somewhat cn- closed. The second possibility would be that some regional groups of Hmong have certain crlltrlral practices or were exposed to something in their environment which predisposed them to sudden nocturnal dcath at a later time.

Secondly, the author looked at past refugee carnp cxpcri- ence. There were six refugee camps in Thailand that the Hmong could havc been processed through before being relocated to a third country. The author checked to see whether the sudden nocturnal dcath cases had been processed through only a certain camp, indicating an experience in the camp which predisposed then) to sudden nocturnal death at a later time.

Thirdly, the author briefly considered past locations in the United States. Since the rnajority of deaths occurred in the United States, the author felt it wol~ld he worthwhile to review this.

Hypothesis Five-Other Aspects of Hmong Culture

The fifth hypothesis was that certain aspects of other Iirnong cultural practices were contributing factors to the ~ r n o n g Sudden Unexpected Nocturnal Death Syndrome. The Hmong have lived semi-autonomously in whatever country they inhabited, from China to the United-States. In Laos, the Hmong lived a significantly different lifestyle as compared to the other ethnic groups around them. Their rice staple was different from the grains consumed by the lowland ethnic groups, and the Hmong commonly ate more corn than others. The Hmong houses were different and the climate of the mountains on which they lived was considerably cooler than the lowlands. In Wcstern countries the Hmong continue to live differently from the cultures arorlnd them. For example, they often live in very crowded conditions, by choice, rather than economic necessity. Many keep the same social and family roles as they were used to in Laos.

It was thought that a study of certain aspects of the Hmong culture might point out some significant point that could be a contributing factor to Hmong sudden nocturnal death. The author investigated the deceased's family size, number of household members, number of dependents, family income, type of housing, educational background, employment rcword, use of alcohol, cigarettes and drugs, consumption of special foods, and hobbies for possible correlation to sudden nocturnal death.

Miscellaneous Theories

In addition to investigating the aforementioned five hypothesis, some theories put forth by other investigators were also considered. These theories included the possibility of sudden nocturnal death being related to exposure to chemical warfare, imprisonment in concentration camps, or that the deaths were related to depression and the stress of

adapting to Western lifestyles. Also considered were the theories put forth for the Filipino sudden nocturnal deaths, to see if the pattern of 1Imong sudden nocturnal deaths supported any of these hypotheses.

At this time, no one else has investigated the author's first four hypotheses. The Centers for Diseasc Control (1981) has circulated a questionnaire pertinent to this study's fifth hypothesis, however, they are studying the sudden noctnrnal deaths of the Laotians as a whole. Since they have not yet published or revealed any results of their survey, the author decided to proceed to cxamine this hypothesis in relation to the Hmong culture only. The author considered other investigators' theories in his study also, as he hoped that in the event that no support for his own hypotheses collld he found, that perhaps he would be able to find indications as to which theories were more probable and thus cncorlrage other researchers to continue further investigations.

Research Design

After considering the hypotheses to be investigated, it was decided that data would be obtained through the utilization of a questionnaire, as well as informally acquiring background information from variorls Ilmong elders and leaders.

Population Description

Thc Centers for Disease Control (1981) reported twenty- six cases and suspected cases of Hmong sudden nocturnal death. Since the total base population of documented Hmong dying sudden nocturnal deaths in the United States was relatively small, it was decided to attempt to study one hundred percent of these cascs. In addition, nineteon other suspected cases of Hmong slidden nocturnal death in the

United States and seven other sllspected cases from four other countries that the author learned about from Hmong community leaders were also investigated. For the purposes of this study, the author defined a suspected sudden nocturnal death case as any Hmong who dicd suddenly, whilc asleep.

The study population totaled forty-five cases, of which thirty-eight deaths were from twenty-two American cities, two deaths were from Thai refugec camps, three deaths were from Laos, and one death each was from Canada and France. The author accepted any deaths reported up until Auglst 31, 1982, the date that marked the close of this study.

Description of Questionnaire

It was decided to design a questionnaire for a bi-lingual investigator to verbally interview family members of the deceased. The questionnaire was written in English and not translated into Hmong as only the investigator would han- dle the questionnaire. The primary reason-for this was that many Hmong persons are unable to read, even in the Ilmong language, and would have had difficulty in filling out a questionnaire on their own. The format of the clues- tionnaire was designed for easy verbal questioning as well as so that the data could more easily be entered into a computer for analysis.

The questionnairc obtained data on the place, date and time of the deaths; histories of the deceased's movement from Laos to Thailand, then to a third country; the age, marital status, number of children, numher of dependents, number of household members, type of house, level of education, job history and income level of the deceased; whether the deceased ate any special foods; the deceased's usage of alcohol, tobacco, drugs and opium; what the deceased's religious background had been; the deceased's history of

health problems, usage of Hmong traditional healing practices or usage of Western medical systems; what subgroup and clan to which the deceased belonged and whether the deceased had any relative who died a sudden nocturnal death; whether the deceased had been exposed to chemical warfare: whether the deceased had been interned in a concentration camp; whether the deceased had appeared to be depressed or having mental health problems prior to death; whether the deceased had appeared to have had a nightmare at the time of death; whether the deceased consllmed fish or fish products, and what the deceased had eaten for his or her last meal and how heavy a meal it way; and what the deceased families' beliefs were regarding the cause of death.

I

Procedure for Gathering Data

Families of the six cases of Hmong sudden nocturnal death occurring in Portland, Oregon, were interviewed per- sonally by the author. For the remaining thirty-two cases which occurred in twenty-one other United States cities, the author conducted telephone interviews with the deceased's families. Family members of the three cases which occurred in Laos and the two cases from Thailand had already relocated to the United States. Therefore telephone interviews were obtained from them also. For the one case in Canada and one case in France, the author also conducted telephone interviews with family members of the deceased.

The author first attempted to interview the spouses of the deceased. In the event that the spouse was not available or preferred not to be interviewed, a family member who lived in the household of the deceased at the time of death was questioned in place of the spouse. In some cases, when the family requested it, the family clan leader was interviewed instead, as this is customary in the Hmong culture.

The telephone interviews lasted approximately twenty to thirty minutes each. It was conducted completely in the Hmong language. In addition to the survey clucstions, notes on any family comments regarding any segment of the questionnaire were jotted down. This sorrietimes gave a better reflection on thc family beliefs about the sudden nocturnal deaths.

Yroc~dure for Data Analysis

Survey results were analyzed using the Columbia Re- search Center, Vancouver, Washington facilities which utilized a Hewlett-Packard HP3000 computer. Hesponses for all forty-seven questions of the survey were tabulated by frequency, percentage and adjusted percentage (disregarding any not applicable, don't know or missing responses) figures. In addition, selected cross tabulation studies were made.

Since the survey poplilation was so small, only forty-five cases, it was difficult to decide what to consider a significant percentage of responses. The anthor arbitrarily decided that, if more than fifty percent of those responding to a question indicated the same response, this would be considered significant.

CHAPTER 4

Results

The survey sample was unfortunately somewhat small in size, being only forty-five cases. However, there were no other known families with sudden nocturnal death victims available for interview. The great majority of the sudden nocturnal death cases, thirty-eight cases, seem to have occurred in the United States. It cannot be determined at this time whether the Hmong in the United States have a higher death rate than Hmong in other countries, or whether there is better documentation, reporting and publicity in the United States as compared to the other countries.

Of the forty-five cases studied, only three were female, the other forty-two cases being male. Undoubtedly, Hmong males are much more at risk than Hmong females. Forty- one of the victims wcre married individuals, while only three were still single and one was widowed. This high percentage of married-cases is to be expected as custom dictates that Hmong men and women marry early. Most who marry stay married, and even if a divorce or a case of becoming widowed occurs, most soon remarry. Usually, only the hand- icapped are not married by the age of twcnty.

The age range of the victims fell between sixteen years of age to one case who was seventy-five years old. As swn in Figure 1, the number of deaths increased dramatically in the twcnty to twenty-nine-year-old range and peaked in the thirty to thirty-nine-year-old range. Deaths remained high in the forty to forty-nine-year-old range, then declined through the fifty, sixty and s e ~ e n t ~ - ~ e a r - o l d ranges. This corresponded to the Centers for Disease Control's (1981) findings.

Figure 1

Age Distribution

-20 20-29 30-39 40-49 50-59 60-69 70-79

Age at Time of Death

The majority of deaths occurred during thc night hours as these deaths were associated with sleep. Thc highest number of deaths were found in the early morning hours, as is shown in Figure 2. This conforms both to what thc Centers for Disease Control found and to the pattern found in the Filipino sudden nocturnal death studies in Hawaii. Al- though there were two deaths which occurred in thc early cvcning, these deaths also occurred while the victims slept. It is not unusual for some Hmong individuals to sleep very early in the evening, as some still follow the pattern, as they used to when living in Laos, of going to sleep when the sun goes down.

From 1973 to 1979, from zero to three Hmong sudden noctrlrnal deaths were found per year. In 1980, the number of deaths almost quadrupled and remained high in number throughout 1981 and 1982, as shown in Figure 3. It is difficult to guess whether this sudden rise in numbers o f deaths was due to better documentation and increased interest in the phenomenon of sudden nocturnal death, or whether it reflects a true rise in thc death rate.

Figure 2

Time of Death Distribution

P.M. A.M.

Time of Death

Number of Deaths per Year

Year of Death


Table 1 shows that the study population of Hmong victims of the sudden nocturnal death syndrome were divided in their religious preference. Twenty-four, or fifty-three and a third percent, retained their traditional beliefs in An- cestor Worship. The other twenty-one persons were divided bctwcen Protestant, Catholic and Christian Missionary Alli- ance beliefs. However, of thcse same twenty-one persons, fifteen individuals had once bccn ancestor worshipers. Only six cases indicated no background of traditional religion although three of these cases had changed from one Christian

religion to another at some time. At least thirty-nine of the cases had some basis for fear of ancestor, nature spirits, evil spirits or ogrcs, and belief in the power of curses.

Tahle 1

Rdigious Preference of the Dcceascd

Catholic

B y.l

Ancrstor Worship

CI

E O Christian 2 Missionary

Alliance

Tahle 2 shows the numbers and percentages of the persons interviewed who felt that the deaths in their families were caused by a religious or related problem. This included the categories of ancestor spirits, curses, loss of religion and nature spirits, as well as culture shock and depression. Cul- ture shock was included in this group because the one family that indicated this response said that the deceased had been unable to assimilate into Western society because he was overly distressed about not being able to continlie his tradi-

tional religious practices. Depression was also included as the four Hmong families who stated they felt this was the main cause of death for their relative, felt that the deceased's depressions were caused by the inability to perform religior~s ceremonies fur their ancestors. Two cases even fclt that the deceased's depressions were caused he- cause their ancestors were unhappy and therefore caused mental and physical problems for the victims in an attempt to communicate their needs. Although the largest response of the survey sample wa! that they did not know what caused the sudden nocturnal deaths, among those who had an opinion on the major cause of death, fifty-six and three tenths percent indicated they fclt the deaths were caused or related to the inability to keep up traditional religious practices.

Table 2

Opinion of C a w of Death

Absolute Relative Adjusted Frcc111~11cy Frer111c:ncy Frccl~~cncy

Ancestor Spirits Culture Shock Curscs nepression 1.cm of Religion Nature Spirits

Sub-Total Natural Causer; Poison Chemical Warfare Other Don't Know

Total

Hypothesis Two- Utilization of Traditional Health Practices

Only ten of the forty-five families indicated that the deceased had had a history of some type of health problem. Table 3 shows where in the body the problem had been located and the length of time the victims had had the problem. When indicating the location of the ailment as either "head," "arms" or "legs," it usually meant the victim suffered from muscular aches. When the response was "chest,"

" it usually meant a cough. When the response was stomach," it usually indicated a problem of digestion. The survey utilized this method of identifying health problems, as this method was most easily understood by Hmong persons without formal education.

Table 3 History of Health P~oblcms

[.enah of Time with Problem

2-3 6-12 ' + 12 months months months Total

Head

Arms

Y 2 Chest ?z a

g Stomach .- CI

Of the ten cases with a history of health problems, seven had btun under Wcstern medical care as shown in Table 4. No one with a history of health problems admitted to under- going any Hmong traditional healing practices.

Table 4

Utilization of Wcstern Medical Care

Under Wcstern Mtdical Care

Yes No Don't Know Total

6 Yes a E a

2 Don't Know 0 c.

iz

In addition to the seven with a history of health proh- lems, eight others, who presumably had short-term medical problems, also utilized Western medical facilities. This makes a total of fifteen cases, or one third of the study popnlation, who utilized Western medical systems. Table 5 shows what type of health problems for which the fifteen cases were under Western medical care. Table 5 utilizes the same method of identifying a health problem as was used in Table 3.

All thosc interviewed denied knowledge of the victims of sudden noctllrnal death utilizing any Hmong treatments or therapy for health problems, either for long-term or short-

term medical problems, as is shown in Table 6. Thirty- seven cascs claimed the deceased had not been using Hmong herbs, been consuming special Hmong foods, were under- going spiritual healing practices, or were receiving counsel- ing from Hmong elders. Eight answered that they did not know if their deceased relative had utilized any of these practiccs.

Table 5

Health Problems Under Western Medical Care

Head Neck Arms Chest Stomach Feet Back Eyes Othcr Not Applical~lu

YCS

Nu Don't Know

Absolute Frequency

Relative Freq~~ency

Adjusted Frequency

6.7 13.3 6.7 6.7 13.3 6.7 6.7 6.7

33.3

Usage of Hmong Traditional Treatments

Absolute Relative Acljustcd Frequency Frequency Frecpcncy

Hypothesis 3-Hmong Subgroups, Clans and Lineages

Twenty-five of the deceased belonged to the Green Hmong subgroup, while twenty cases belonged to the White Hmong subgroup. Table 7 shows which of the twenty-three known Hmong clans had sudden nocturnal death cases. The Lee clan suffered the highest number of deaths, having eight sudden nocturnal death cases. The Thao and Vue clans had six deaths each, also relatively high numbers of deaths. Thc rest of the cases were scattered between ten other clans. Ten clans had no reportcd cases of sudden nocturnal death.

Table 7

Subgroup and Clan Distribution

G r e n White Total Creen White Total

Cha

F-0 Cheng

73 $ !i

Her

Kue

Moua

2? M c 2 Vang

-a

2 i vuc n

Xiong

Yang

Total

Only eight of those interviewed stated that the deceased had had a relative who also died a sudden nocturnal death. Thirty-six cases claimed the deceased had had no relative who died in such a manner, and one did not know. Table 8 shows what the relationship to the deceased was. Five of the relationships were close family members, being father, mother, brother or son. Cousin is a term which reflects varying degrees of closeness in relationship. For the Hmong, it could mean a true cousin or a distant relation who happens to bear the same clan name. For the three cases citing "cousin" as a relativc dying a sudden nocturnal death, the author learned that in each case, the cousin had been in the same clan and lineage as the other cases. Thcsc cight cases reflect seventeen and cight tenths percent of the study population.

Relationship of Relative Dying Sudden Death with Deceased

- Father

Mothcr Brother

Son Cousin

Not Applicat)lc Don't Know

Total

Absolute Relative Adjusted Frr:rl~lr:ncy Frcxl~~(:ncy Frcqrlcncy

2 4.4 25.0 1 2.2 12.5 I 2.2 12.5 1 2.2 12.5 3 6.7 37.5

36 80.0 -

1 2.2 - -


The majority of Hmong families interviewed seemed not to have undergone widespread secondary migration while living in Laos. Those born in a province usually stayed and

lived there, only moving from village to village to escape war zones. Table 9 shows the provinces of Laos where each of the deceased was born. Quite a large majority, fifty-five and six tenths percent, were born and raised in the province of Xieng Khouang, a north-central province of Laos where much of the military action during the 1960s and 1970s took place.

Birthplace of Deceased

Absolute Helative Adjostcd Frequency Frqiicncy Freqrlency

Borikarle Luang Prabang

Nam Tha Sayabury Vicntiar~e

Xieng Khouang Don't Know -

'I'otal

The forty-one of the deceased who came to the United States, France or Canada, came through six different Thai refugee camps, as is shown in Table 10. The largest group, twenty-two cases, or forty-eight and nine tenths percent, came through Camp Vinay. Some of the families interviewed had lived in np to three of the refugee camps prior to being resettled in a third country. In the interviews the families stated that the most common departure place to third countries was Camp Vinay. Often, refugees in other camps would be relocated to Camp Vinay prior to admittance into a third country.

Upon arrival in the United States, only a few of the deceased and their families underwent secondary migration. Most of the victims died in the American city where they had first settled. Table 11 shows the number of Hmong sudden nocturnal deaths which occurred in each state. Thc

number of deaths documented from other countries are also included. The state of California had thirteen deaths, the highest number of sudden nocturnal deaths of any other state. The deaths were spread out between eight California cities. Six deaths occurred in Santa Ana, and one death each in Fresno, Iiuntington Beach, Long Beach, Sacramento, San Diego, and westminister. Next, the states of Minnesota and Oregon each reported six deaths. The deaths in these states occurred in the cities of Minneapolis-St. Paul and Portland, respectively. The rest of the deaths were scattered throughont nine other states and four other countries.

Thai Refugee Camp

Absolute Relative Adjusted Frequency Frequency Frequency

Ban Tong Nam Phong

Nam Yao Nong Khai

Soptua Vinay

Not Applicable

Total

United States California Hawaii Illinois Iowa Michigan Minnesota Oklahoma orcgor1 Pennsylvania Rhode Island Washington Wiscur~sin

Other Countries Canada France I.acxs Thailand

Total

Absolute Hclativt: Adjr~stt~l k'rerluency Frequency Frequency

Hypothesis Five-Other Aspects of Hmong Culture

The majority of the deceased lived with very large families. This was to be expected, not only because custom dictates that couples have many children and that children should come as soon after marriage as possible, but because most Hmong persons live with their extended families. Most of the deceased had between three to six children. However, twelve cases had seven or more children. The three who did not have any children were the unmarried cases. Besides being responsible for spouse and children, most of the deceased had lived with, and were responsible for, extended family members such as elderly parents, uncles and aunts, or any nieces or nephews whose parents had died.

Table 12

Income Level of Families

'I'otal Family Inmrne

$300- $So& $800- Don't - $300 $4W $799 $999 - $1000 Know Total

I1 or morc

Don't Know

Total

With such largc numbers of dependents, most of the deceased, who were heads of household, were unable to make a salary large enough to comfortably support their family. Most wives and elders in the Hmong families did not work. Many families lived on public assistance. Table 12 shows the number of dependents the deceased had in relation to the family income. The majority of families could be classified

as low income or in the lower socio-economic bracket. Eleven cases did not know the family incornc per month or did not wish to reveal the information. Of the thirty-three families that responded, the greatest number of families, fourteen of them, were in the five hundred to seven hnn- dred ninety-nine dollar per month range. Many of the deceased had five to ten dependents, indicating they were responsible for the well-being of a large family with very limited incomes.

Table 13

Living Space of Families

7 or nl)~l't 1-2 3-4 5-6 More Know 'I'otal

Don't Know

Total

'I'he majority of deceased were living in either an apartment or house, with a few who lived in a duplex or town- house. However, the size of the majority of residences was very small for the number of people living in them. Table 13 shows the number of household members in relation to the number of rooms in their residences. Most seemed to have lived in very crowded conditions.

Many of the deceased had had very limited educational background. Unfortunately, this is true for most of the Hnlong adult population at this time. Only those below the age of eighteen who relocated to a Western country have had the opportunity to easily seek higher education, or any education at all. Table 14 shows that over seventy-five percent of those who died had only sixth grade education or less. Thirty-five and six tenths percent had had no education whatsoever.

Tablc 14

Level of Education of Deceased

Absolute Ht:lativc Frtrl~~ency Frequency

Adjusted Fnxll~ency

No Education 16 I-5th Grade 11 6th Crade 1 1 10th Crade 5 Hi& School fliplorr~a 1 1-3 Years College I

-- Total 45

Eighteen out of the forty-five cascs were former soldiers in Laos. This rcprcscnts forty percent of the study population. The next largest group were farmers. Farmers repre- sent thirty-one and one tenth percent of the study population or fourteen cases. Thc three female cases had been former homemakers. ITowever, in Laos, this always meant that they assisted their spouses or menfolk on the farm. This

means that in actuality, there was a total of seventeen cases from a farming background. Only a smattering of the sudden nocturnal death cases had been professionals or other- wise employed, which is shown in Table 15.

Table 15

Former Employment in Laos

Absolute Ht:lativc Frcupcncy Freqt~ency

Agriculture 14 31.1 Homemaker 3 6.7 Profewional 3 6.7 Soldier 18 40.0 Student 3 6.7 Other 4 8.9

Total 45 100.0

Of those that resettled in a Western country, a full sixty- five percent, or twenty-six cases, never became employed in their new country, as is shown in Table 16. The thirteen cascs that were employed had widely differing types of jobs. One was a farmer, one was a caseworker, one was a cook, seven worked in various industries, and the others had miscellaneous other types of jobs.

Table 16

Employment in New Country

Full-time Enlployed Part-time Errlployed Never employed in new country Not Applicable

Total

Absolute Hdative Adjusted Preqr~ency Frequency Frculr~cncy

13 28.9 32.5 1 2.2 2.5

Table 17 shows that thirty cases or sixty-six and seven tenths percent of the sample population wcrc thought never to have corlsurried alcoholic beverages. Five cases rarely drank and eight sometimes drank. Only one of the deceased was thought to have heen a heavy drinker. This is in agree- ment with Iimong Icadcrs' opinions that alcoholisni is not a major problem of the IImong race.

Table 17

Alcohol Usage

A1l~)lute Rclativt: Adjusted Frequency Yreqtrency Frequcncy

Never Used 30 86.7 68.2 Rarely Used 5 11 .1 11.4 Sornctirncs Used 8 17.8 18.2 Heavy Usage 1 2.2 2.3 Don't Know 1 2.2 -

Total 45 100.0 100.0

Those that used addictive drugs werc even fewer in number than those who consurned alcohol. Only three cases were thought to rarely use drugs and onc to sometimes use drugs. Thirty-nine werc thought never to have used addic- tivc drugs. Most Hmong individuals had not been in West- ern countries long enough to be introduced to drugs such as heroin, cocaine and other addictive drugs. In Laos, a few Hmong sometimes used opium, which they produced themselves in their fields. There is a rumor that opium is being smuggled in from Thailand for Hmong consumption in the united States. However, even if this were true, Hrnong elders and leaders of the community fccl that only a very small percentage of the population is consuming it. The low rate of usc of addictive drugs among the sudden nocturnal death cases is shown in Table 18.

Table 18

Use of Addictive Drugs

Absolute Relativc Adjusted Frequency Fr~quency Frerlllcncy

Ncvcr Used 39 86.7 90.7 Rarely Used 3 6.7 7.0 Sometimes Used I 2.2 2.3 Don't Know 2 4.4

Total 45 100.0 100.0

Cigarette usage was not common to the forty-five cases of sudden nocturnal death either. Thirty of the deceased were thought never to havc used cigarettes, as shown in Tahle 19. Although six were thought to smoke heavily, and one was thought to be a chain smoker, seven cases constitute a relatively small percentage of the study population.

Tahle 19

Use of Cigarettes

Abwlnte Relative Adjusted Frequency Frc~lucn~y Frequency

Never U.xd 30 Rarely Used 1 Sometima Used 6 Hcavy Usage 6 Chain Smokcr 1 Don't Know I

Total 45

When asked if the deceased had consumed opium in Laos or Thailand, forty cases denied opium usage. Only three were thought to havc formerly been addicted to opium, and one each was thought to rarely use it, or sometimes use it, as

is shown in Table 20. This is not surprising as lndochinese refugees were screened closely in refugee camps for possible addiction to opium prior to being allowcd admittance into the United States.

Tahle 20

Use of Opium in Laos or Thailand

Absolute Frequency

Relative Frequency

Adjusted Frequency

Never Used 40 Rarely Used I Surnc+irnes Uxd 1 Addidtxl 3

Total 45

Table 21 shows that the victims of Hmong sudden nocturnal death had a variety of hobbies. Hunting and musical in- struments seem to have been the most popular hobbies. However, eleven cases had no hobbies at all, and nine families did not know whether the deceased had had any hobbies.

Table 21

Hobby of Deceased

Hunting Fishing Music Weaving Sewing Soccer-Outdoor Sports Othcr Nonc Don't Know

Absolutc Frequency

Relative Frequency

Adjusted Frequency

16.7 5.6

19.4 2.8 2.8 8.3

13.9 30.6 -

It was surprising that only three out of the forty-five families said that the -deceased ate food differently from their families. These three did not consume what was considered luxury items snch as pork or beef organs as might be expected of traditional Hrnong heads of household. Instead, two of them seemed to be on special diets for medical reasons. One consumed rice soup frequently, a dish known for its easy digestibility which many Hnlong cat when they suffer from upset stomachs. Another atc only unsweetened foods, and the last one was fond of fried cggs.


Poison in a Concentration Camp

Only one of the forty-five deceased had once been captured and put in a concentration camp during the war in Laos. This case was a woman who spent between six and twelve months during 1977 in "Ban Ma Tan," a concentration camp located in-the province of Sayabory. Iler fanlily said that the deceased had said she saw "medicine" being mixed into the prisoners' food while she was interned.

Exposurc to Chemical Warfare

Table 22 shows the response to the question of whether the deceased had ever been exposed to chemical warfare. Although only six families definitely knew their deceased relativc had been exposed to chemical warfare, all who responded that they did not know if the deceased had been exposed to chemical warfare, also said that perhaps when es- caping from 1,aos into Thailand, they and the deceased had

passed through areas that had been sprayed with chemicals. Only thirteen families felt the deceased had never been exposed to such chemicals.

Table 22

Exposure to Chemical Warfare

Absolutt: Relative Adjusted Frequency Frequency Frequency

Y cs Nu Don't Know

Total

For the six cases that were allegedly definitely exposed to chemical warfare, all exposures took place in the province of Xieng Khouang, Laos. This was the only known province in Laos to be allegedly subjected to repeated chemical warfare attacks.

Stress of Cultural Assimilation

Only five families felt that the deceased had exhibited un- uslial behavioral patterns before death. The types of behav- iors exhibited are listed in Table 23. Only one case was thought to be depressed and another was talking of suicide.

Table 24 shows that seven families felt that the resettlement experience of their deceased relative had been "not very good" and four felt it had been "bad." Twenty-three felt the experience had bccn "all right" or better. Some of the deceased may have been under more stress than their families knew of, but the responses to the survey indicated that the majority of families interviewed felt that the deceased had not been suffering severely from a poor resettlement experience.

Table 23

Type of Behavior

Absolute Relative Adjusted Frequency Frwl~~wcy Frequency

Depression Talk of Suicide Disoriented Nervous Habits Sleep Problem Not Applicahlc

Total 45

Wondcrfill Good All Right Not Very Gocd Bad Not AI)l)licahlc- Ilon'l Know

Total

Table 24

Resettlement Experience

Ahsolute Frequency

Relative Frequency

4.4 17.0 28.9 15.6 8.9

1 1 . 1 13.3 - 100.0

Adjusted Frequcncy

5.1 20.5 33.3 17.9 10.3 12.8

Relationship to Filipino Sudden Nocturnal Death Studies

There were three th~wries put forth on possible causes for the Filipino sudden nocturnal deaths in Hawaii. The first was that the deaths were caused by terror originating from nightmares. The second was that the sudden nocturnal deaths were caused by a large meal followed by a nightmare. The third theory was that the deaths were caused by the consumption of certain fish or fish products which con- tained toxic matters.

Table 25 shows that of the twenty-eight sudden nocturnal deaths that were witnessed, in twenty-five of the cases, the families did not feel that the victim had been having a nightmare at the time of death. Only three families felt the deceased was having a vivid nightmare at the time of death.

Table 25

Appearance of Nightmare Prior to Death

Absolute Hdative Adjusted Frequency Frequency Frequency

Ym 3 6.7 10.7 No 25 55.6 89.3 Don't Know 17 37.8 -

Total 45 100.0 100.0

Thirty-eight of the deceased had eatcn dinner as their last meal prior to death. Two had had lunch, four had had a snack, and one family did not know what the deceased's last meal had been. Table 26 shows that the majority of families felt that the size of the last meal was regular or light. Only one of the deceased had eaten heavily.

Table 26

Size of Last Meal

Abolutc Hdativc Adjusted Frequency Frequency Frec111ency

Heavy Regular Light Very Light Not Applicable Don't Know

Total

Thirty-six of the families remembered the contents of thc last dinner. No one had caten fish or fish products the night of the death. Commonly consumed wcre chicken, pork, vegetables and rice. Table 27 shows the frequency the deceased consumed fish or fish products per wwk. Four cases never ate fish or fish products, and the majority of sudden nocturnal death victims only ate these itcms one or two times per week.

Table 27

Consumption of Fish or Fish Products

A1)~)lute Rdativr: Adjusted Frequency Frequency Frcxl~~ency

Never 1-2 tinleslweek 3-4 timeslwwk Don't Know

Total

CHAPTER 5 Discussion of Results

Whoever was approached by the author was willing to be interviewed about the sudden nocturnal death in their family. The author feels he was able to talk to the families of nearly one hundred percent of the sudden nocturnal death cases which occurred prior to August 31, 1982. All the farni- lies who were interviewed gave the author thc impression of willingness to sharc information and scumed to be very frank about how they felt in regards to the sudden nocturnal death. Thc author therefore feels the results he obtained ac- curately rcflcut the Hmong opinions and feulings aabout the Hmong Sudden Unexpected Nocti~rnal Death Syndrome.

Discussion of Hypotheses

First, evidence to support or disclaim the five major hypotheses of this investigation were sought. Then secondly, evidencc to support or disclaim certain other investigators' theories were reviewed.


It did not scwm that religious preference was an indicator of sudden nocturnal death. Sudden nocturnal death struck both Christians and Ancestor Worshippers alike. Hrr~ong leaders estimate that in the United States, about half of the population has converted to Christianity, while the other half remain ancestor worshippers. Of the thirty-eight sudden nocturnal death cases that died in the United States, exactly half, nineteen cases, were Christians and half were

Ancestor Worshippers. Thus, it seems that conversion to Christianity did not significantly increase the risk for sudden noctllrnal death.

In Laos and Thailand, the percentage of those converting to Christianity is much smaller, so the fact that the five deaths occurring in these countries were all ancestor worshippers probably reflects the greater poplilation of traditional worshippers rather than implying that being an ancestor worshipper increases the risk of sudden nocturnal death. Since there was only one death each from Canada and France, it was impossible to make any conclusions about these two cases. However, the author's theory that those who converted to Christianity suffered higher levels of stress and an increased risk of sudden nocturnal death was disproven.

The ?uthor speculates that this may be becallse both Christian and non-Christian Hmong were under similar stresses caused by the inability to resolve religious conflicts. Hmong Christians could have been under stress because many probably still retained some of their traditional beliefs about ancestors and spirits, even after conversion. Those converting to Christianity often experienced peer disap- proval, the anger of other clan members, and were sometimes even ostracized. Another reason conversion to Christi- anity may have caused increased stress levels was that many families who converted did not truly understand the concepts of Christian religion. Some of the Hmong families who resettled in Western countries converted because their sponsors were church groups or religious voluntary agencies. Ont of respect for their sponsors, or desire to obtain greater services and assistance, many of these families gave up their traditional religion to become Christian without truly taking any comfort from their new religion. Therefore, it seems that peer pressure and lack of understanding of Christianity may cause some Hmong Christians to have anxieties about not fulfilling their expected traditional religious duties, particularly towards their ancestors.

The non-Christian Hmong suffered from stress over not being able to perform traditional expected religious duties. The author discovered that of the nineteen Hmong families resettled in Western countries who continued in Ancestor Worship, every one of them expressed the view that they were not able to satisfactorily perform certain religious ceremonies. Reasons for this were that, besides being fearful of the police and breaking public health laws, many complained that since they were not allowed to raise or slaugh- ter animals in their homes, it was difficult to find adequate livestock necessary for Hmong ceremonies. Some families said that due to the disruption of village and clan groups caused by relocation, they were unable to find a Hmong re- ligions leader or other family members to help in the perfor- mance of correct ceremonies. Others cited that living in an apartment was not conducive to providing a central pillar for ancestor spirits to live in.

Of the nineteen non-Christian families in Western countries, eleven expressed the definite opinion that the sudden nocturnal deaths were caused by religious problems. This is over half of the non-Christian cases. In addition, many of the other families who said they did not know what the cause of death was, expressed in later conversations with the author that they felt the deceased had been concerned over the inability to perform traditional religious ceremonies, but that they were not sure this was the major cause of death. Many were reluctant to openly state their ideas about the subject at first, as they had no proof and were fearful that the American community would ridicule their beliefs.

Five of the sudden nocturnal death cases were from the countries of Laos and Thailand. This represents only a little more than one tenth of the study population. Many more sudden nocturnal deaths seemed to have occurred in Wcst- ern countries, particularly in the United States where it is perhaps more difficult for Hmong families to keep up traditional religious practices. It may be that the lower numbers of sudde; nocturnal deaths in Laos and Thailand only

means that these countries have not documented all their sudden noctlxrnal death cascs, or that communication was not as good there. Howcver, the Hmong grapevine is fairly reliable as a source of information, and there seems to be no other known cascs of sudden nocturnal deaths in Laos or Thailand. All fivc of the sudden nocturnal death cascs in Laos and Thailand were practicing ancestor worshippers. None of these fivc families felt that the inability to worship properly was the primary cause of death, probably because in these colxntries people can easily perform traditional religious ceremonies. Ilowever, one family felt that the death was caused by a curse, and another family felt the death was caused by an offended nature spirit. These two families felt the death of their relative was caused by a religious problem, but a problem not related to the inability to perform religiorls ceremonies.

In summary, a total of thirtccn of the non-Christian families interviewed felt that the suddcn nocturnal deaths were caused by religious problems-either the inability to perform traditional ceremonies in Western countries, or other types of religious problems in Laos and Thailand. The Christians were understandably reluctant to admit that they felt the sudden nocturnal deaths wcrc related to traditional religious factors, but the author still feels that the Hmong Christian familics experienced some stress over their change of religion for various aforementioned reasons.

The author did not prove that beliefs about ancestor spirits, nature spirits, evil spirits, ogres, curses, loss of sonl, or the inability to perform traditional ceremonies actr~ally caused sudden nocturnal death or was a contributing factor in the sudden noctlxrnal death cases. I-Iowever, he found many indications that a fairly large group of Hmong, probably both Christians and non-Christians, have anxieties caused by not performing traditional religiorls practices. This prohably contributed to raising the stress level in many of the sudden nocturnal death cases.

It seemed that those most susceptible to religious stresses are IImong males who are heads of household. This is because in the Hmong society, it is the head of household who is responsible for religious activities. Women rarely lead or perform any religious rituals. Since it is the head of the hollsehold who is responsible for the well-being of the family's ancestor spirits, it is the men to whom spirits are thought to commonly cause illness. The majority of sudden nocturnal death cases happened to male heads of household. This supports the author's theory that the inability to perform traditional religious ceremonies or other religiolls problems, along with other day to day difficulties of adapting to a new life, can raise the stress level of many Hmong individuals and trigger mental health problems, health problems, and sudden nocturnal death.

Hypothesis Two-Utilization of Traditional Health Practices

Many of the sudden nocturnal death ca.es, twenty-seven of them, seemed to have been previously healthy individuals. However, there were eighteen who had had either a history of medical problems, or had had a short-term illness. Eighteen cases represents forty percent of the study population. The Centers for Disea~e Control had stated that most of their sudden nocturnal death victims had been previously healthy individuals. This study found indications that a sizable group had had some sort of illness prior to death. Ten of the cascs had had a history of some sort of health problem while eight had had short-term illnesses prior to death.

Of the ten who had a history of a health problem, or long- term illness, seven had been under Western medical care and three had had no health care at all. None of this group were able to find Hmong traditional healing treatments. All eight of the short-term illnesses had recently been to a West- ern medical facility to treat the illness. None of these had

been able to find I-lmong traditional healing treatments either. In fact, out of the forty-five cases, not a single one had been able to utilize I-Imong traditional healing treatments.

The author feels that many Iimong either don't utilize Western medical facilities, as evidenced by the three cases with long-term medical problems who did not seek medical assistance, or underutilize Western medical facilities, probably because Western medicine is not able to provide for the Hmong population's health needs. It seems that much of the Hmong population is not getting adequate health care, either western or Hmong. his in itself could cause deterioration of health. Although this does not prove that the inability to find traditional healing treatments triggers sudden nocturnal death, it strongly indicates that a sizable percentage of the Hmong community is unable to find the type of health care they desire. This probably adds a great deal of additional stress to their lives, which may cause mental health problems, health problems, and perhaps sudden nocturnal death.

Hypothesis Three-Hmong Subgroups, Clans and Lineages

First reviewed under this hypothesis was whether membership in either the Green Hmong subgroup or the White Hmong subgroup was a risk factor for sudden nocturnal death. The author first investigated what percentage of the Hmong population belonged to the Green Hmong and what percentage belonged to the White Hmong.

Hmong leaders estimate that the overall world population of the Green Hmong subgroup is slightly larger than the White Hmong subgroup. However, in the United States, an average of several Hmong leaders' population estimates indicates that the numbers of the Green Hmong subgroup make up only about forty percent of the Hrnong refugee population. The rest, some sixty percent, are made up of

members of the White Hmong subgroup. Based or1 a figure of forty-six thousand five hundred Hmong in the United States, this translates to approximately eighteen thousand six hundred Green Hmong and twenty-seven thousand nine hundred White Ilmong.

There were thirty-eight Hmong sudden nocturnal deaths documented in the United States. Twenty-one were from the Green Hnlong subgroup and seventeen were from the White IImong subgrobp. This means that for the Green Hmong subgroup there were twenty-one deaths in a population of eighteen thousand six hundred; and for the White Hmong, there were seventeen deaths in a population of twenty-seven thousand nine hundred people. Since the nurnbers of deaths in the United States Green Hmong subgroup were higher and within a smaller population, it seems that membership in the Green Hmong subgroup is an increased risk for sudden nocturnal death. This indicates possible genetic origins for these deaths. However, since the population study is so small at this time and the population numbers of the Hmong in the United States only estimates, it is not yet possible to bc sure of this theory. If more deaths occur, and a more accurate count of the population is made, a better evaluation collld bc done.

Next, the author investigated whcther membership in certain Hmong clans was an increased risk for sudden nocturnal death. The thirteen clans with documented cases of sudden nocturnal death were the clans known to be larger in population than the other ten clans. The lack of deaths in these ten clans probably only reflect their smaller numbers rather than a decreased risk for sudden nocturnal death. There are no statistics on population numbers for each of the IImong clans, either. However, Hmong leaders feel that the thirteen larger clans are fairly et~ual in numbers, with only minor variations. If this is true, then membership in thc Lee, Thao and Vllc clans may indicate a slightly higher risk of sudden nocturnal death, and that membership in the Cha, Cheng and Hang clans would seem to imply a lower risk from sudden nocturnal death.

The Lee, Thao and Vuc clans had deaths in both the Green and White subgroups. However, some clans had deaths only in onc subgroup, such as the four Lo clan deaths being all White Hmong and the three Moua clan deaths being all Grccn Hmong. This indicates the possibility that membership in certain clans and subgroups could mean an increased risk for suddcn nocturnal death, which again indicates that the cause for sudden nocturnal dcaths could be genetic in origin.

The last section of this hypothesis was the thcory that sudden nocturnal death rates might be higher in certain lineages. In support of this theory, some eight of the suddcn nocturnal death cases had had a relative in the same lineage who also died a sudden noctllrnal death. Although this is a somewhat small percentage of the study popnlation, there are some interesting features in this group of eight cases. Five of the deceased had had a close family member who also died. Two of these cases were a father and son of the Moua clan. Of the three who said a cousin had also died, all three were cousins to each other, all were members of the 1,ee clan, were all Green Hmong, and all shared the same lineage. This last group of cases is certainly enough to suggest that membership in some lineages could possibly he a risk factor for sudden nocturnal death.

All this evidence, while not proving that sudden nocturnal dcaths are caused by a genetic problem, certainly supports the possibility of this theory. Should additional deaths occur, it will be more possible to prove or disclaim this theory.


The first area of investigation of this hypothesis was to see if geographic origin was a contributing factor to Hmong sudden nocturnal deaths. Upon review of the deceased's birth~laccs, it was found that more than half of the study

population had been born in the province of Xieng Khou- ang, Laos. This northeastern province of Laos, which shares a borderline with North Vietnam, underwent large scale military action during the 1960s and 1970s. It was in this province that many report witnessing repeated attacks of chemical warfare.

First the author investigated what the United States Hmong refugee population numbers were from cach province of 1,aos. If over half o f the tImong population in the United States was born in Xieng Khouang, then the high numbcr o f deaths from this province wollld only reflect their greater population numbers.

It was impossible to obtain definite statistics on the birth- places of the Hmong in the United States. 'l'he author con- srllted a Hmong community leader, Hang Sao, former colonel in the Royal Lao Army and in charge of security, who was one of the few known persons to have kept records on the numbcr of Hrnong living in cach province of Laos and also cstimates on the number of Hmong refugecs from each Laotian province who eventually emigrated to the United States (Hang, 1982). Table 28 shows his estimates of the Ilmong population in Laos by province or area.

Table 28

Hmong Population in Laos

Provincu: Poprllatior~

Luang Prabang Phongaly Sam Nr:ua Sayahory and Luang Narr~ Tha Vientiane, Khamonane arid Borikanr Xir:ng Khouang

Total

Table 29 shows Hang Sao's estimates of the percentages of refugees from different Laotian provinces presently living in the United States. Based on a total population of forty-six thousand five hundred Hmong, it was possible to estimate the numbers of refugees from different Laotian provinces. These numbers as well as the numhers of Hmong sudden nocturnal death cases coming from each province were included in Table 29 for easy reference. The sudden nocturnal death cases from other countries were deleted in this calcu- lation.

Table 29

Hmong Population in the United States From Laotian Provinces

Estimated "/o Estirnatcd Numbers of Hmong of Ilmong Population Population Number of

Birthplace in U.S. in U.S. I ~XIL'WYI

Luang Prallang 15 6,975 Luang Nam Tha

and 15 6,975 Sayahry

Borikane and 15 6,975

Vientiane Xieng Khouang 30 13,950 Sam Neua 20 9,300

Total 100% 46,.51)0

The ratio of the number of deceased from Xieng Khouang to the pop~llation of Xieng Khouang Hmong refugees in the United States was considerably larger than the ratios of rcf- ugccs from other provinces of Laos. This indicates that being born in Xieng Khouang was indeed an increased risk factor for sudden nocturnal death. Whether the reason for this was because of the genetic pool of the Hmong in Xicng

Khouang, cultural aspects of this group of people, or due to being exposed to something in their environment such as war and chemical warfare, is open for debate at this time. Certainly, further research into these possibilities is needed.

When considering common refugee camp experience as a possible factor contrihuting to sudden nocturnal death, the author noted that a large group of Hmong came through Camp Vinay. However, although many refugees complained about very poor sanitary conditions, the unavailability of medical care, the lack of and poor quality of food and cloth- ing, and some even suspected that their food was poisoned, at least three sudden nocturnal deaths occurred to individuals who had never been in a refugee camp. It therefore seemed unlikely that the Thai refugee camp experience significantly affected the Ilmong sudden nocturnal death rate.

It did not seem that common United States geographical locations was a contrihuting factor in the Hmong sudden nocturnal death cases either. One reason is that the number of deaths in each state somewhat reflects the varying Hmong population sizes of each respective state. In other words, states with larger Hmong populations had higher numbers of sudden nocturnal death. The number of sudden nocturnal deaths for the size of Hmong population in France, Thailand and Laos is disproportionately small in comparison to the United States. This could possibly indicate that life in the United States as a whole is an added risk factor contributing to Hmong sudden nocturnal dcath. Per- haps the Hmong find life in the United States more stressful than in those countries. The author continues to consider the possibility that not all the sudden nocturnal death cases in these countries were reported. Continued surveillance is needed to check on this. The one death in Canada reflects the small TImong population of that country.

Hypothesis Five-0 ther Aspects of Hmong Culture

The majority of the Hmong sudden nocturnal death cases lived in very crowded conditions on a limited income. I-low- ever, they seem to have been living in similar conditions as other minority groups in the lower socio-economic bracket. Therefore, perhaps their housing, the number of people they lived with and their income levels were not major factors contributing to the Hmong Sudden Unexpected Noctur- nal Dcath Syndrome.

Nevertheless, Hmong family life and social roles are somewhat different from other minority groups in the same socio-econorriic bracket. Family ties remain very strong. Many heads of household continue to strive to maintain complete authority and responsibility for each of their household members. However, there is some minor role changing caused by Western influence which can cause increased stress levels for many Hmong adults, particularly heads of household. After coming to Western countries, the Hmong head of household has had to get used to being dependent on children for translation services and often on Welfare checks to support his family. It seemed very likely to the author that this loss of dignity and authority over his family, along with other stresses, caused mental health and health problems for many individuals, and could even have eventually triggered sudden nocturnal death. Certainly it seems that being a Hmong head of household involves a great deal of stress which could increase the risk for sudden nocturnal death.

Former education level did not stem to bc a contributing factor to the sudden nocturnal death syndrome. Although the majority of deceased had very limited educational background, this is true for most of the Hmong race at the prcs- ent time.

Formcr job occupation also did not seem to be a common factor in the sudden nocturnal death cases. Most who died

were former soldiers or farmers. Again, most Hmong refugee adults in Western countries also have this same background.

Job occupations in the West could not have b~wn a common factor for IImnng sudden nocturnal deaths because so many of the cases had nevcr been employed in their new country. In addition, those who had become ernploycd had jobs differing in place and type from each other.

Consumption of alcoholic beverages cannot have been a common feature of the sudden nocturnal death cases as so few of the deceased had consumed alcohol regularly. Alco- holic hevcrages are traditionally consumed only at wed- dings, during the new year's celebrations and other very spccial occasions.

Most of the study population was thought not to have becn using addictive drugs, nor to have been former opium users. This is probably true as most of the Hmong sudden nocturnal death cases would not have known how to pro- cure illegal drugs from local drug distributors because the majority did notspeak enough English to solicit drugs on the streets. Hmong leaders know of no Hmong drug dealer, so Western addictive drugs were probably not readily available to the sudden nocturnal death victims. There continues to be some allegations that relatives in Thailand axe sending opium to families in the United States for home consurnp- tion and for resale. Even if this were true, most of the families felt the deceascd had not recently used opium and had had no prior history of using opium. This is also probably true as Hmong and other refllgees were screened carcfully in the Thai refugee camps for opillm addiction prior to entry into the United States. Anyone found with a trace of opium in his or her urine was denied entry. All this indicates that it is unlikely that addictive drugs or opium usage contributed to the sudden nocturnal dcath syndrome.

Most of the study popnlation were thought not to have hcen cigarette smokers. The deceased did not seem to have any hobbies in common. Most of the deceased did not eat

foods separately from their families. Therefore it is probable that none of these factors were a significant contributing factor to the Hmong sudden nocturnal death rates either.


After investigating this studies' five hypotheses, the author considered the possibility of other investigators' theories being feasible. This includes some theories on Hmong sudden nocturnal deaths and some on the Filipino sudden nocturnal deaths.

Poison in a Concentration Camp. IImong leaders report many stories from those who had been interned in a concentration camp, many of whom claimed to have witnessed poison being mixed in their food. This story has been con- firmed by many different former prisoners. However, since only one of the deceased had formerly been imprisoned, this collld not be a common factor in the Hmong sudden noctilrnal death syndrome.

Exposure to Chemical Warfare. The possibility that exposure to chemical warfare was a contributing factor to the sudden nocturnal death syndrome cannot be ruled out. Al- though only six cases were thought to have b~wn definitely exposed to chemicals, all six exposures happened in the Xieng Khouang province of Laos, the only known Laotian province to have experienced repeated chemical warfare attacks. More than half of the sudden nocturnal death victims were former residents of Xieng Khouang. In addition, the group of Hmong coming from Xieng Khouang had a death rate from sudden nocturnal death that was higher than Hmong groups from other Laotian provinces. It is possible that exposures to low levels of chemical residues in and around the Xieng Khouang area could have predisposed some individuals to sudden nocturnal death at a later time.

Men were more likely to have been exposed to the chemicals as many were soldiers who spent a lot of time in the open. Also, in the Hmong society, the male farmer was the one who wa. expectcd to scout for new fields and prepare the new fields for cultivation. Thus, they were more likely to have been exposed to any chemical residuals. Women spent more time in vegetable gardens which were closer to the villages. Most of the sudden nocturnal death cases were former male soldiers or farmers, the two groups most likely to have been exposed to chemicals.

Another factor to consider is that the number of Hmong sudden nocturnal deaths soared upwards and stayed high from 1980 on. This abrupt rise in the number of deaths (see Figure 3) corresponds to Hmong military leaders' opinions that although chemical warfare began in Laos as early as the 1950s, large scale chemical gassing started in 1979.

Arguments against the possibility that exposure to chemical warfare was a contributing factor to sudden nocturnal deaths are: 1) that the Filipinos were not exposed to chemical warfare, and 2) that some of the Hmong who died sudden nocturnal deaths, died prior to the advent of known chemical attach in Laos. However, much of the military action in World War I1 took place in the Philippines, and exposure to some sort of chemical or biological warfare could have taken place during those years. Alternately, it must be considered that the Filipino sudden nocturnal death syndrome and the Hmong sudden nocturnal deaths syndrome may not be exactly the same. Many of the Filipino deaths were associated with an inflammation of the pan- creas (Death Mystery in Hawaii, 1948), something not found in the Hmong sudden nocturnal death cases.

Another thing to consider is that some early Hmnng sudden nocturnal dcaths seem to have been confused with diphtheria. This discasc is marked by the formation of a false membrane in the throat by a bacterium which pro- duces a toxin causing inflammation of the heart and nervous system. Some who died of diphtheria gave the surface appearance of having the same symptoms of sudden nocturnal

death, especially as the victims also made the same type of groaning or gurgling sounds at the time of death. So perhaps the early Hmong sudden nocturnal deaths were not really sudden nocturnal deaths.

Considering all these possibilities, it seems that we cannot rule out that exposure to chemical warfare weakened some individuals and predisposed them to sudden nocturnal death at a later time. Rather than avoiding the issue, further research into this possibility must be encouraged.

Stress of Cultural Assimilation. The majority of the families interviewed felt that the deceased had not exhibited any obvious signs of mental health problems. Only five of the families indicated that the deceased had had a change in behavior prior to death; and of these five, only two were felt to have been very depressed or talking of suicide. Despite this, the author still feels that many of the deceased were under stress from a large variety of reasons. Some had anxieties over not being able to reconcile religious differences, or not being able to find the type of medical assistance they felt they needed. Others were distressed over their changed roles of-being dependent on Welfare and children, rather than being a breadwinner and family head of household. An- other reason for stress is that some heads of household felt unable to cope in their new society, much less continue to make decisions for all their many dependants. Perhaps thc sudden nocturnal death cases did not exhibit clinical signs of mental health problems, nevertheless, the stress level must have been high in most of these cases.

Most of the families felt that the deceased had had an "all right" resettlement. Unfortunately, there is no direct translation for the word "rcsettlement" in the Hmong language. Most Hmong who answered this question meant that the deceased had had an "all right" experience from the time they left Thailand until they were either able to get public assistance or the head of the household found a job. They did not mean the deceased had had an "all right" life after living in their new environment after the first couple of

months. In talking with the families of the deceased, many told the author that the deceased had not adjusted well to life in a third country. Many were very homesick, missed relatives, mourned for lost ones, or were just unable to accept their new roles and lifestyle. Therefore, despite the responses to the questionnaire, the author still feels that the stress of cultural assimilation very possibly affected many of the sudden nocturnal death victim's lives and may even have triggered the sudden nocturnal deaths. This is a difficult theory to prove, but it must nevertheless be considered a possibility.

Relationship to Filipino Sudden Nocturnal Death Stud- ies. The pattern of Hmong sudden nocturnal deaths did not support any of the three theories proposed for the Filipino sudden nocturnal death syndrome. Only three of the Hmong families suspected the deceased of having a nightmare at the time of death. This is far too small a number to support the first Filipino sudden nocturnal death theory that nightmares triggered these deaths. All except one of the Hmong families did not feel the deceased had eaten an unusually heavy meal prior to sleeping the night of the death. This contradicts the second theory that the Filipinosudden noctrlrnal deaths were caused by a heavy meal followed by a nightmare. Lastly, none of the Hmong had eaten fish or fish products at the last meal before death, and many did not eat fish or fish products frequently. In fact, four of the Hmong cases never ate fish or fish products. Therefore sudden nocturnal death caused by toxins found in fish or fish products is not likely. The Filipino sudden nocturnal death theories had already been considered unsubstantiated, so alternate theories for both syndromes should be considered.

Conclusions

The results of this research established that some of the theories for the cause of the Hmong sudden nocturnal death syndrome were not probable. This study found that housing, income, number of household members, prior job occupations, recent job occupations, refugee camp experience, geographic location in the United states, former education level, the consumption levels of alcohol, addictive drugs, opium or cigarettes, consumption of special foods, and hobbies'were not common factors to those Hmong who died a sudden nocturnal death. Internment in a concentration camp was also not a common experience. In addition, this study reinforced other investigators' opinions that the theories put forth regarding the Filipino sudden nocturnal death syndrome were unsubstantiated.

Several hypotheses remain possible, although none were definitely proved. The first is that the cause of the Hmong sudden nocturnal death syndrome is related to a problem of genetics. This dovetails with what medical investigations are supporting; that the deaths are related to an electrical cardiac conduction failure, probably caused by a congenital defect (Centers for Disease Control, 1981). It would seem that certain populations have a small percentage of individuals who are susceptible to sudden nocturnal deaths. Some populations, such as the Hmong, may have a higher percentage of the population being at risk. However, what needs to be considered is what causes these individuals at risk to die at a certain time. Many of the sudden nocturnal death victims had lived throughout the war, survived a refugee camp experience and a traumatic move to a new country, only to die suddenly at a later date. Thc factor which triggers these sudden nocturnal deaths has not yet been firmly established.

This study proposes that there are two possihlc triggering mechanisms for the sudden nocturnal deaths, although the author does not mean this to imply these are thc only two possible causes. Other investigators may suggest other valid

possibilities also. The first triggering mechanism for sudden nocturnal death this study proposes to be possible is that the stress to certain individuals caused by the inahility to continue traditional religious practices in Western countries or other religious difficulties; or stress caused by other reasons such as the inahility to find traditional healing practices or the difficulty in adapting to a new lifestyle, can cause a variety of hcalth problems, including eventual sudden nocturnal death. The s t ~ n n d possible triggering mechanism this study proposes to be possible is that exposure to chemical warfare weakened some individuals and predisposed them to sudden nocturnal death at a latcr date.

Recommendations

The first rccomrnendation of the author is that the West- ern medical communities should encourage more research into possiblc psychological causes of sudden nocturnal death and also into the possibility that exposure to chemical warfare could predispose some individuals to later sudden nocturnal death. Few investigators have bwn willing to tackle these controversial subjedts, but it is hoped that this research will encourage others to attempt this difficult task. Research into these theories is still vcry much needed.

The second recommendation of the author is that West- ern health practitioners acknowledge the possibility of benefits from alternate health delivery systems. Although some Hmong are utilizing Western health services to a limited ex- tent, some of the Hmong who are ill continue to show rduc- tance in accepting Western medicine. There seems to he an cxccssive fear of surgery, which keeps some individuals from visiting a doctor's office. It is recommended that Western medical practitioners be sensitive to this and other fears and that they facilitate and encourage Hmong families to seek traditional healing arts and pursue their traditional religion in conjunction with Western medicine. Whether this pro-

vidcs actual mcdical benefit for the patient or not, is imma- terial. It is sure to provide psychological benefits and create an atmosphere in which the patient is more likely to feel re- assured and confident of returning to good health.

The third recommendation of this study is that Western medical facilities employ and utilize hicultural and bilin- gual workers at all levels, from menial to professional. There is a tendency for health agencies to hire interpreters at the paraprofessional level only, excluding bilinguallbicultural persons from policy and decision making functions. More bilinguallbicultural professionals should be integratcd into the Western hcalth services delivery system, which hopefully will benefit both the minority ethnic groups as well as the Western mcdical profession as more cult~xrally appropriate health programs may bc developed.

The author's fourth recommendation is for the Hmong communities in Wcstern countries. He llrgcs that they assert their rights to continue in their traditional religious and health practices. They should lobby for exemptions to allow them to sacrifice animals in their homes. Each community should be encouraged to compile a refcrral list of Hrrlong healing practitioners and religious leaders so that newly arrived Hmong families can more easily seek the assistance they need. Hmong leaders should inform their communities that surgery is not the only method of treatment from West- ern medical systems, and that recommended surgery can be refused. They should also inform their communities that medical treatments from Western practitioners can be beneficial for a large variety of illnesses and that Hrnong families can lltilize both traditional and Western hcalth delivery systems at thc same time without offending anyone.

If these recommendations are put into practice, it is probable that a greater percentage of Hmong persons will utilize both Western and Hmong health delivery systems. Hopeful- ly, this will promote bctter general health and mental health status in the Hmong population and perhaps even a reduction in sudden nocturnal death rates. Although this reduction is not guaranteed, higher utilization of Wcstern and

Hmong health delivery systems will certainly lower the level of anxiety and stress for Hmong people as well as raise the cinality of their lives.

In closing, it is the hope of the author that this study will promotc thc understanding of the benefits of accepting al- tcrnatc hcalth delivery systems. It is the aim of this study to encourage the provision of cross-cultural medical services for the Hmong, Indochinese, and all other minority groups.

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Documents

HMONG - RENINCous sudden nocturnal deaths in the Hmong population. Al- though these deaths also strike other ethnic groups such as the Cambodian, Filipino, Japanese, Laotian, Mien